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CHRONIC URETHRITIS 

OF GONOCOCCIC ORIGIN 



BY 

J. DE KEERSMAECKER 

Chief of Service, Diseases of the Urinary Organs at the 
Centraalklinik of Antwerp 

AND 

J. VERHOOGEN 

Agrege at the University of Brussels ; Chief of Service, Diseases of the 
Urinary Organs at the Pvlyclinique Libre 



TRANSLATED AND EDITED, WITH NOTES BY 

LUDWIG WEISS, M.D. 

Attending Physician to the Genito- Urinary and Skin Service, German Poliklinik 
Dermatologist to the Hebrew Orphan Asylum, New York, etc. 



NEW YORK 

WILLIAM WOOD & COMPANY 

M D C C C C I 



K*' 



m Voi* 



THE LIBRARY OF 

CONGRESS, 
Two Copies Received 

APR. 24 190! 

COPYRUIHT ENTRY 

cla'ss 6Lxxc. n». 

COPY 8. 



Copyright by 

WILLIAM WOOD & COMPANY 

1901 



SOount pleasant Iprinterp 

J. Horace McFarland Company 
Harrisbttrg • Pennsylvania 



PREFACE 

The procedures of exploration employed for the nana] 
of the urethra have undergone remarkable improvements 
during the past twelve years. Thanks to these ad- 
vances, it has become possible at present to carry out 
a complete study of urethral pathology. Numerous 
researches have been directed toward this end. Gon- 
orrhea has especially been made the object of important 
researches, and we have been enabled to witness, under 
their influence, the therapy of this affection undergo in- 
cessant modifications, which one will search in vain to 
find duplicated in other special branches of the healing 
art. 

When Desormeaux employed his endoscope for the 
first time, some forty years ago, he endeavored to estab- 
lish a rational classification for the various forms of 
urethritis; but his attempt failed because the method 
was still too imperfect. The discovery of the gonococcus 
came in then to modify the conception which had been 
formed of the pathology of this affection, and endoscopic 
studies were abandoned, while all efforts were directed 
toward the newer route which had been opened up. Un- 
fortunately, Xeisser's discovery had but slight practical 
results, so far as the treatment of chronic urethritis is con- 
cerned. During this period the original instrument of 
Desormeaux underwent successive modificatious. Xitze 
finally proposed the introduction of a luminous source 

(Hi; 



IV PREFACE 

within the urethra itself, almost in contact with the 
mucous membrane to be observed and studied. The in- 
strument which he devised, and which Heynemann, a 
mechanic of Leipsic, afterwards improved under my di- 
rections, possesses the practical qualifications which are 
indispensable to the macroscopic study of the lesions 
met with in the urethral mucous membrane. 

It is thus that a suitable classification of these lesions 
can be established. The results which the urethroscopic 
study of the canal had already given me were confirmed 
by the anatomical researches of Neelsen and Finger. We 
may assert that the pathological anatomy of chronic ure- 
thritis is at the present completely studied. The utility 
of this study is evident. It is impossible to institute the 
treatment of a disease without knowing exactly its lesions. 
It is necessary, in chronic urethritis, as in all other dis- 
eases, to make a precise diagnosis. If this precision is 
insisted upon for affections of the larynx, lungs, eyes, 
bladder, etc., why should it be otherwise for the dis- 
eased urethra ? The term chronic urethritis is quite as 
vague as that of ophthalmia or of gastritis; it masks an 
incomplete diagnosis. 

Finding the gonococcus scarcely completes the insuffi- 
ciency; if it is positive it proves the contagious nature of 
the discharge. Still, a negative result does not authorize a 
contrary conclusion, since it is demonstrated that in most 
chronic cases the microbe is found only exceptionally. 

To arrive at a precise diagnosis and apply a rational 
therapy, we must resort to urethroscopy; all other instru- 
ments employed in the exploration of the canal give in- 
sufficient results. While urethroscopic study of the canal 



PREFACE V 

permits us to arrive at the required exactitude from a 
diagnostic point of view, it gives also equally important re- 
sults regarding treatment. It was thus, in a large measure, 
that I was led, in the treatment of chronic urethral gon- 
orrhea, to employ a particular mode of dilatation. 

Furthermore, once treatment is begun it becomes pos- 
sible, by means of the urethroscope, to follow, step by 
step, the progress of the cure, to predict the exacerbations 
which may arise, and to recognize finally the moment, 
when all lesions having disappeared, the patient may be 
considered as cured. 

More than fifteen years ago I described the method of 
dilatation which I have always since employed, and which 
has been gradually adopted in Germany and in foreign 
parts. I have added few modifications since this time, but 
the method has proven its own worth in the hands of my 
pupils, and its results are incontestable. I should, how- 
ever, add that it cannot be employed with any certainty 
of success without the aid of urethroscopy. 

The study of urethroscopy is long and laborious indeed, 
but the difficulties which a science presents should never 
discourage a serious worker; only superficial natures take 
fright at them. The appearances that the urethroscope 
reveal present an enormous variety, and are modified in 
the different portions of the canal. The lesions are often 
but faintly marked and difficult of recognition; but with 
a good method one learns, little by little, to know what he 
is about. In the work which Doctors De Keersmaecker 
and Verhoogen now present to the medical public, they 
have exposed with distinctness the principles of urethro- 
scopy. Its study will thus become an almost easy matter 



VI PREFACE 

for him who is willing to devote to it the necessary time, 
for he can only attain it by perseverance and after having 
attentively examined a large number of patients. 

As to the method of treatment which I have advised, 
it gives indisputable results. To succeed, the novice 
should conform himself exactly to the rules which expe- 
rience has dictated. Later on, when he knows how to 
appreciate to their full extent, the results of each one of 
his interferences, he may permit himself, on his own re- 
sponsibility, to take such liberties as he may deem useful; 
but before reaching this point he should have had an 
experience of several years. Furthermore, it is indispen- 
sable to be able to follow, step by step, during the whole 
course of treatment, the results obtained; and to accom- 
plish this he must frequently examine the canal by means 
of the endoscope. No maneuver should be undertaken 
without a previous examination to determine whether it is 
surely indicated. 

The results, however, which will thus be obtained are 
remarkable, and we can say that every chronic gonor- 
rheal urethritis may surely be cured, provided that the 
lesions of the mucous lining of the canal are solely of 
gonococcic origin. 

F. M. OBERLANDER, 

Dresden, July 1, 1897. 



EDITOR'S PREFACE 

After the exhaustive preface of the great authority on 
urethroscopy, there would scarcely be any need of another 
preface by the editor of this volume, were it not for a few 
words of explanation to the American medical reader. 

The treatise in its original form deals with chronic 
gonorrhea of the urethra only. In view of the extremely 
frequent complications of the contiguous seminal glands, 
it seemed eminently appropriate to the editor to append 
a chapter dealing with some aspects of their involvement, 
dependent upon the gonorrhoic process. 

Some gaps in the original work, as pointed out by 
many reviewers, prompted me to the attempt to incor- 
porate in this work Chapter XIV, on Palpation and Ex- 
pression of Cowper's, the Prostate, and the Seminal 
Glands; while Chapters XI, XII, and XV represent another 
effort, to acquaint the reader with details on the treat- 
ment of Chronic Gonorrhea, Urethral Asepsis, and the 
question of Gonorrhea and Marriage, respectively. Also 
revision and enlargement on the subjects of urethroscopy, 
instillation, flushing, gonococcus life, and treatment. 

The urethroscope, or endoscope as it is still inappro- 
priately called, has proved to be indispensable to the 
specialist, and ought soon to become as favored an in- 
strument in the hands of the versatile general practitioner 
as the otoscope or laryngoscope. 

The information it gives us in the diagnosis and treat- 

(vii) 



viii editor's preface 

merit of gonorrheal urethritis can only be appreciated by 
those who have been enlightened by its revelations. The 
exactness with which it enables us to perform rational 
dilatation under its control, the distinctiveness to discover 
granulations, diverticuli, or polypi, responsible for many 
an inexplicable, obstinate discharge, cannot be superseded 
by any other instrumental contrivance in use. Besides 
showing the well -characterized changes of chronic ure- 
thritis, it enables us to diagnose the earliest onset of a 
relapse, which the most painstaking exploration with 
bougies, etc., would fail to reveal. It enables us to local- 
ize circumscribed patches, erosions, and ulcers for topical 
applications; to treat or destroy the main abodes of the 
gouococci, the diseased urethral glands; to presage re- 
lapses, to determine the stage of infiltrations, and to 
pronounce a cure. In short, it furnishes information 
unobtainable by any other method or methods. 

But in thus extolling the virtues of the urethroscope, 
I do not claim it to be a cure-all, to the exclusion of 
other well-tried methods in use. The reliance on bacte- 
riologic and microscopic methods solely for diagnosis, 
without using clinical means, is a one sided procedure. 
Without doubt, the employment of both methods will 
bring us as near to perfection in the diagnosis and treat- 
ment of chronic gonorrheal affections as is possible in 
the present state of scientific research. 

The joint authors of this volume have admirably suc- 
ceeded in giving to the specialist an exhaustive and 
scientific presentation of urethroscopy in all its details, 
which, it is hoped, will prove a welcome guide! 

The translation of this treatise was conceived bj r the 



EDITOR S PREFACE IX 

editor while pursuing his studies abroad, and enjoying* 

the privilege of meeting the foremost representatives of 

urethroscopy. 

The editor is conscious of some short-comings; yet 

he feels that his attempt to make urethroscopy available 

to the general practitioner, and acquaint his American 

confreres with so useful a department of our science, 

may not be in vain. If he has partly succeeded in this 

effort, he will consider himself amply rewarded for his 

labors. 

LUDWIG WEISS. 

77 East Ninety-first street, 
New York, March, 1901. 



Those portions of the text included 
between brackets ( [ ] ) have been added by 
the Editor. 



CONTENTS 



PAGE 

Preface iii 

Introduction 1 



PART FIRST 

ANATOMO- PATHOLOGIC STUDY 

CHAPTER I 
Anatomy of the Urethra— 

I. Conformation 9 

II. Structure 11 

CHAPTER II 
The Gonoccus — 

I. Preparation and Staining . 17 

II. Morphological Features 23 

III. Cultures 25 

IV. Biology of Cultures 26 

V. Inoculations 27 

VI. Clinical Study of the Gonococcus 28 

VII. Extension and Generalization 30 

VIII. Persistence and Increase 31 

IX. Secondary Infections 34 

CHAPTER III 
Acute Urethritis 35 

CHAPTER IV 

Pathological Anatomy of Chronic Urethritis 39 

(xi) 



XU CONTENTS 

PART SECOND 

DIAGNOSIS 

CHAPTER V 

Suppuration — 

PAGE 

I. The Quantity of Secretion 49 

II. Microscopical Character of Secretion 50 

III. Localization 52 

IV. Kollman's Procedure 55 

CHAPTER VI 
Disturbances of Sensation 59 

CHAPTER VII 

Examination op the Patient — 

I. Direct Examination 63 

II. Sounds and Urethrometers 64 

CHAPTER VIII 

Urethral Endoscopy (Urethroscopy) — 

I. Instruments and Operative Technique 68 

II. Endoscopy of the Normal Urethra 85 

III. Endoscopy of the Pathologic Urethra — General Survey . 91 

Description of the Lesions Met with in the Tissues of 
the Canal — 

I. The Mucous Membrane 96 

II. The Epithelium 100 

III. The Folds 104 

IV. The Glands, and Lacunae of Morgagni 106 

Special Description of the Various Forms of Chronic 

Urethritis 118 

V. Endoscopy of the Posterior Urethra 140 

VI. Appendix — Papillomatous Urethritis 151 



CONTENTS Xlll 

PART THIRD 
TREATMENT 

CHAPTER IX 

General Treatment — 

PAGE 

Regimen 154 

Internal Medication 156 

CHAPTER X . 
Local Treatment — 

Methods 161 

Mechanical Treatment 168 

Topical Remedies . 172 

CHAPTER XI 
Notes on the Treatment op Chronic Gonorrhea 179 

CHAPTER XII 
Notes on Urethral Asepsis 187 

CHAPTER XIII 

Mechanical Treatment: Instruments — 

I. Bougies — Antrophores 195 

II. Dilators 197 

III. General Rules of the Method of Dilatation 207 

IV. Special Rules of the Method of Dilatation — 

Anterior Urethritis 213 

Posterior Urethritis 224 



CHAPTER XIV 

Palpation and Expression of Cowper's, the Prostate, and 

the Seminal Glands 227 

Observation of Patients 234 



XIV CONTENTS 



CHAPTER XV 

PAGE 

Chronic Gonorrhea and Marriage 239 



CHAPTER XVI 

Conclusions 249 

Plates I to IV 252-258 

Index 259 



CHRONIC URETHRITIS OF 
GONOCOCCIC ORIGIN 



INTRODUCTION 

The actual progress in the study of chronic urethri- 
tis during the last few years has completely modified the 
conception which had been formed of this very frequent 
disease. Therefore we have thought that it would be use- 
ful to take up the study of the question in its entirety 
again, pajdng especial regard to the facts as they actually 
exist. There is no chronic disease so wide -spread as 
gonorrheal-urethritis — its tenacity and its resistance to all 
forms of treatment are features universally known. We 
may add that the special gravity which it presents from a 
sociological point of view, and which is often hidden under 
insidious forms, did not clearly stand forth until recent 
discoveries of gynecology made it clear. 

[The French use the word "blennorrhagie urethrale" to 
denominate what we call in the vernacular "clap," and the 
Germans, "Tripper." As a technical expression the words 
blennorrhea or blennorrhagia possess the advantage of being 
logically correct, but devoid of a more specific meaning. 
Blennorrhea comprises every discharge containing pus, 
while the term gonorrhea denotes only a flow emanating 
from the genital organs. The ancients identified the dis- 
ease with the seminal flow. (Hence the name gonorrhea — 
from yoVos, seed and pw, to flow.) Neisser, in giving the 
causative coccus the name gonococcus, conveyed to us 

A (1) 



Z CHRONIC URETHRITIS 

the meaning of a parasite contained in the flow. Although 
the generic term, gonorrhea, is etymologically incorrect, 
it is almost universally used in its application to a specific 
type of inflammation affecting the genito-urinary organs, 
and answers all practical purposes well.] 

Besides, physicians themselves do not appreciate in 
general the importance of chronic urethritis. ■ The whole 
tableau of the symptoms which it presents passes only too 
often unrecognized; only the purulent discharge, the goutte 
militaire, seems to deserve their attention. The importance 
that is accorded this symptom becomes even so predomi- 
nant that it appears to constitute, in itself, the entire 
disease. All the efforts of therapy are directed against it, 
and if it disappears the disease is declared cured. 

Nevertheless, whether there be a discharge or not, the 
disease continues its evolution, frequently carrying with it 
consequences of the most disastrous nature; for chronic 
gonorrhea of the urethra is not, as is often thought, a 
benign affection without gravity. It is, on the contrary, a 
redoubtable enemy, which seems at times, it is true, to 
remain inactive, but never becomes wholly disarmed. 

At each instant the disease may take on again an acute 
form; it extends without cessation, and its immediate or 
remote complications form one of the most outbranchiiig 
chapters of pathology. Finally the patient who is affected 
furnishes a focus of infection for others, the more danger- 
ous because it is almost always unrecognized. 

The affection may be transmitted unwittingly or inno- 
cently from the man to the woman, and provoke in the 
latter the occurrence of serious accidents of genital blen- 
norrhagia with all its consequences. 

[As early as 1872 Noeggerrath of New York maintained 
and emphasized the fact, alluded to by Bernultz in 1859, 
that gonorrhea, and especially the latent form, is the cause 
of many serious ailments in women. The acute and chronic 
metritis, endometritis, perimetritis, ovaritis are, in nine- 



INTRODUCTION 3 

tenths of the cases, due to latent gonorrhea in man. We 
know that gonococci may lie dormant in Littre's glands, 
or in the secure depths of Morgagni's crypts, in Cowper's, 
or in the ducts of the prostatic glands, or in the remote 
abodes of the seminal vesicles. The "morning drop " of 
the patient may not show the presence of any gonococci, the 
scrapings of the urethral mucosa, the careful and trying 
examination of the threads in the urine may all prove 
negative, and yet there might be gonococci hidden in the 
contiguous tissues and glands. There they lie, seemingly 
innocuous in their latency, until a sudden mechanical im- 
pulse sets them free. Excesses in Baccho and Venere and 
irritations of the genitalia of a kind to cause often-repeated 
hyperemia; over-indulgence, better known as the much- 
complained of "strain"; chronic prostatitis, perchance 
even constipation, all these may cause, in a mechanical 
way, an expression of gonococci and a new invasion of 
the urethral mucosa by them. 

We have but lately seen such a case of auto -reinfection 
in a young man who had gonorrhea two years ago. He 
went through a well-conducted treatment of permanganate 
of potash irrigations in vogue at that time, and afterwards 
with astringents. No discharge being present, he consid- 
ered himself cured. Lately he appeared with a discharge 
for the origin of which he could not account. The patient 
we knew to be trustworthy, and there was not the slightest 
necessity to withhold the truth. He had had no sexual 
intercourse for six weeks. He complained of excessive 
constipation and of very frequent nocturnal seminal emis- 
sions. On examination, the meatus did not show any sign 
of inflammation, there were no pains on pressure on the 
fossa navicularis, — in short, not the slightest sign of an 
acute process. The discharge showed a few gonococci. 
We carefully washed out the anterior urethra with a 
warm boric acid solution until the fluid returned absolutely 
clear. On massaging his prostate, a viscid white fluid 



4 CHRONIC URETHRITIS 

soon trickled out of his meatus. Microscopic examination 
showed the presence of very numerous gonococci. Whence 
did these come ? There can be no doubt that they came 
from the prostate. The patient, when he ceased treat- 
ment, must have had an uncured posterior urethritis which 
infected the prostate. Attenuated virulency of the gono- 
cocci did not at that time set up an acute prostatitis, but 
caused a chronic involvement of that organ with gonococci 
which remained latent until, by accident, they became again 
active. A thorough examination of a candidate for mar- 
riage is therefore a necessity.] 

We will not dwell upon all the accidents to which this 
transmission niay give rise. We will, however, recall the 
fact that from a social point of view, sterility in the woman 
is only too often the consequence of this gonorrheal infec- 
tion of the genital tract and of the surgical mutilations to 
which it leads. 

When gonorrhea is thus introduced into a family, are 
we to limit ourselves to looking after the purulent ophthal- 
mia of the infants, the vulvo- vaginitis of the little girls, 
or the gynecological affections of the mother ? 

Should we not, on the contrary, go back to the origin 
of all these ills, and cure, first of all and in a definite 
manner, and completely, the gonorrhea of the head of the 
family ? 

Now it is quite rare that this result is obtained, owing to 
the fact that the diagnosis of gonorrhea in man is not made 
with all the exactitude and precision necessary. Besides, 
until recent times, it was a m3 T sterious disease whose path- 
ology was vague and whose lesions were scarcely known. 

The discovery of the gonococcus (1879) cleared up this 
question. Since then works on this topic have multiplied 
and taught us, little by little, that gonorrhea is a specific 
disease, due to the action of a particular microorganism — 
the gonococcus. In its development upon the mucous 
lining this microbe produces in it an acute inflammation, a 



INTRODUCTION 5 

urethritis of typical course whose violence and spread may 
be more or less extensive according* to the resistance of 
the subject and, without doubt, also, the virulence of the 
infection. 

At the end of a certain time the period of acute evolu- 
tion is terminated, and the disease begins to retrogress. 

At times the cure is effective in this manner, but most 
often gonorrhea, even subjected to a well-directed treat- 
ment, passes gradually into a chronic state. Lesions per- 
sist which, instead of disappearing have, on the contrary, 
a strong tendency to spread without ceasing. 

Chronic urethritis is, accurately speaking, made up of the 
subsequent evolution of these lesions. 

At the same time that this pathogenic conception of the 
disease was taking definite shape, the processes of investi- 
gation indispensable to diagnosis were being continually 
perfected. The canal of the urethra became directly acces- 
sible to visual observation, and its slightest details could be 
studied. 

From this time on it became possible to follow here the 
evolution of gonorrheal lesions in situ, to determine, with 
exactness, its seat and extent, to observe its progressive ad- 
vance or its cure. In a word, we were enabled at last to 
make a precise diagnosis. 

The practical results of these advances were not slow 
in showing themselves. Up to this time the treatment of 
chronic urethritis had been purely empirical, and the phy- 
sician found himself guided only by some vague precepts 
derived most often from incomplete observations. 

All the general or local treatments, which promised to 
be appropriate for the urethra because they had given 
good results in the treatment of suppurative processes else- 
where, were successively advocated with enthusiasm and 
then abandoned after a more or less ephemeral existence. 

A few local applications alone were retained because a 
prolonged usage had shown their beneficial effects. Such 



b CHRONIC URETHRITIS 

was the case with the balsamics, the astringents, and the 
nitrate of silver. These were employed, however, more or 
less in a haphazard way, without their utility being accu- 
rately predicted or their action controlled. Such should no 
longer be the case. Henceforth the treatment of chronic 
urethritis cannot be left to chance. 

An accurate diagnosis will be followed by a rational 
treatment; but, to arrive at this result, we must be able 
to make a complete study of the question. 

The domain of gonorrhea in man is indeed vast. The 
disease can, in certain cases, become generalized and in- 
vade the entire economy. In its chronic state it is almost 
always limited to the genital and urinary organs. 

In this work we shall limit ourselves to a study of 
chronic gonorrheal urethritis. For other localizations of 
the disease (epididj-mitis, cystitis, prostatitis, etc.), we 
must refer the reader to special treatises. 



PART FIRST 

ANATOMO- PATHOLOGIC STUDY 

Chronic gonorrheal urethritis results from the evolution 
of lesions produced by the gonococcus upon the urethral 
mucosa. It succeeds directly upon the clap, when the acute 
phenomena have become ameliorated and when the disease 
takes on a slow course, which may become indefinitely pro- 
longed. This passage into the chronic form is well defined, 
from an anatomic point of view, by the appearance. of con- 
nective-tissue fibers at the seat of parvicellular infiltration, 
which invades the mucosa during the acute form. These 
changes appear after a variable lapse of time, generally 
toward the end of the second month of the disease; but 
they may also be retarded or show themselves much later. 
In other respects they do not correspond to a well-defined 
modification of the symptoms, because they do not appear 
at the same instant in the whole extent of the canal; they 
make their debut, on the contrary, in a few spots, only 
to become generalized little by little. It is thus that 
gonorrhea passes slowly and gradually from the acute into 
the chronic form ; and from this fact it results that one 
can never precisely indicate the moment when chronic 
urethritis begins. 

To make the evolution of the disease clear, we will first 
briefly recall certain points in the anatomy of the normal 
urethra and the chief characteristics of the gonococcus, 
which are indispensable; w T e will then investigate the char- 
acteristic lesions of acute gonorrheal urethritis aud, finally, 
we will observe the alterations which the canal undergoes 
during the whole course of chronic urethritis. 

(7) 



8 CHRONIC URETHRITIS 

[The onset of chronic urethritis is not dependent upon 
the time which has elapsed since the acute attack, but upon 
the clinical symptoms which have developed after the acute 
attack has spent its fury. While some gonorrheas will 
run their course and finally wind up with a perfect cure, 
others — the majority, by the way — will lose all the char- 
acteristics of the acute process and slowly drift into a state 
of lessened activity. 

Besides, some gonorrheas, especially repeated attacks 
of them, sometimes start ab origine with a slow intensity, 
representing a lenient form, commonly called subacute 
gonorrhea. But in the majority of cases acute gonorrhea, 
after having lost its highly inflammatory character, passes 
into a sluggish state, with neither pain nor any other func- 
tional symptoms, and accompanied only by a moderate 
secretion (subacute gonorrhea), which invariably drifts 
either into a latent aseptic urethral catarrh, or in chronic 
gonorrhea proper. 

Therefore it is neither a gonorrhea of long standing, 
nor a refractory form of it, nor the time which has elapsed 
since its onset which characterizes chronic gonorrhea, but 
only the anatomical condition of the mucosa. Through 
natural or artificial healing influences the diffuse char- 
acter of the acute state has given place to circumscribed 
lesions of a lasting character. These consist of erosions, 
granulations, epithelial changes, and of infiltrations of 
the glands and of the deeper layers of the mucosa.] 



CHAPTER I 

ANATOMY OF THE URETHRA 

Works on anatomy describe in detail the situation and 
relations of the canal of the urethra ; ,we will here speak 
only of its conformation and structure. 

I. Conformation. — In the flaccid state the urethra 
is a canal only in theory, for the walls are in complete 
apposition throughout its whole extent. In reality the 
canal exists only when the walls are spread apart to give 
passage to the urinary stream, or for the passage of some 
foreign body. This spreading is then the greater the more 
pronounced the tension to which the walls are subjected. 
They give way by reason of their elasticity, but once the 
limits of this elasticity are passed, they tear. 

The caliber of the canal is thus not constant; it varies 
frequently and within wide limits. When the urethra does 
not functionate, it is reduced to its minimum, and the walls 
lie in apposition. If we make transversal sections of 
a flaccid urethra at different levels we observe that the 
canal has the appearance of a vertical slit in the regions 
of the glans, that it is transversal in the spongy region, 
star -shaped in the membranous portion, and takes on the 
form of an inverted Y in the prostatic region (Fig. 1). 

In the state of distension, on the contrary, the form of 
the canal resembles that of a cylinder of irregular dimen- 
sions. The meatus forms almost always its most con- 
stricted part; it is almost inextensible and its dimensions 
are extremely variable. After the meatus comes the fossa 
navicularis, a small ampulla- like dilatation, which quickly 
contracts into a neck -like narrowing at times greater than 

(9) 



10 CHRONIC URETHRITIS 

that of the meatus itself. Then comes the spongy portion, 
which has the form of a truncated cone, decidedly elon- 
gated with its summit anteriorly, and which consequently 
widens out progressively to attain its maximum at the 
bulb. It is at this point that the canal attains its greatest 
dimensions. Its walls, especially the inferior, are very 
extensible. This extensibility of the lower wall, along 
with the action of the sphincter, which is situated im- 
mediately behind, and maintains the urethra completely 
closed, forms at this point a depression which is the bulbar 
cul-de-sac. Then the canal again becomes narrowed at 
the point where it pierces Carcassoune's aponeurosis, and 



I 3 



^ A 



Fig. 1. Transversal Sections of the Male Uretha at Different 
Levels. (After Quenu.) 

1. At the external orifice. 2. In the middle of the glans. 3. At the 
base of the glans. 4. At the pars spongiosa. 5. At the height of the angle 
of the urethra. 6. At the beginning of the prostata. 7. At the height of 
the verumontanum 

preserves a uniform diameter throughout the whole mem- 
branous portion, to take on a fusiform aspect in the pros- 
tatic region and, for the last time, becomes narrowed at the 
vesical neck. 

The canal then forms a cylindrical, very irregular tube 
whose diameter varies within a wide range, not only from 
one portion and another, but also in the same part, accord- 
ing to the amount of distention which the walls undergo. 
When these dimensions are measured it is seen that the 
deepest parts are the most dilatable. It is thus that we 
can, without inconvenience, dilate the prostatic region up 
to 40 or 45 of the Charriere scale (13 to 15 millimeters). 
The membranous region, which is somewhat narrower, 
can be dilated up to 40; at times, however, it is difficult to 
go beyond 30 (10 millimeters). (Fig. 2.) 

The dimensions of the anterior portion of the canal 



ANATOMY OF THE URETHRA 11 

progressively diminish from the bulb to the meatus. The 
bulbar region is quite as dilatable as the prostatic region, 
even reaching the size of 50 Charr. (16 to 17 millimeters). 
The diameter then progressively diminishes until behind 
the fossa navicularis it is only half that of the diameter of 




Fig. 2. Cast of the Male Urethra. 
(After Sir Everard Howe.) 



the bulbar region (24 to 30 Charr.). As to the dimensions 
of the meatus, of the fossa navicularis and of its neck, they 
are very variable. The average seems to be about 24 
Charr., but we can often go up to 28 or 30. At other 
times, on the contrary, the meatus is exceptionally narrow 
and scarcely admits a very thin bougie, without such atresia 
being due to any lesion whatever. 

II. Structure. — The urethra is formed of several lay- 
ers of tissue which are : 

1. An epithelial layer constituted in the prostatic 
portion by stratified pavement epithelium which passes 
gradually into the cylindric form toward the membranous 
region. The epithelium, in the neighborhood of the blad- 
der, is in all respects similar to the bladder epithelium of 
which it is only the continuation. As we approach the 
spongy portion, the epithelium takes on more and more 
the cylindric appearance. The spongy portion possesses a 
stratified cylindric epithelium. The urethral epithelium is 
smooth, moist, and shiny. It shows by its transparency 
the color of the subjacent mucosa. 

2. A connective -tissue layer constituting the mucous 
membrane. This layer is continuous anteriorly with that 
of the glands. It is fused posteriorly into that of the blad- 



12 CHRONIC URETHRITIS 

der, and consequently is continuous with the mucous mem- 
brane of the ureters and pelves of the kidney. It extends 
likewise into the ejaculatory ducts, the seminal vesicles, 
the vas deferens, and the epididymis. The mucous mem- 
brane of the urethra is very elastic ; it clings firmly to the 
subjacent layers, especially in the prostatic region where it 
is impossible to separate them. 

3. A muscular coat formed of smooth fibers which are 
very thick, especially in the membranous region. The most 
internal layer, and the one whose fibers are the finest, is 
longitudinal; the external layer is circular. At the point 
where the urethra opens into the bladder these circular 
fibers form a veritable sphincter, like a ring, which is indeed 
the internal vesical or prostatic sphincter. In the prostatic 
and membranous regions there exists a third layer of 
striated fibers. In the whole neighborhood of the bladder 
they appear above the urethra, forming a sort of arci- 
form muscle (Finger) held between the prostatic lobes. 
These fibers increase in number as we advance, and when 
the urethra emerges from the prostate, they form a sphinc- 
ter-like ring, external sphincter [the so-called cut-off mus- 
cle,] which is continuous with the muscles of the liga- 
ment of Carcassonne. 

4. An erectile laijer which exists only in that portion of 
the urethra situated anterior to the ligament of Carcas- 
soune, and which is called the corpus spongiosium of the 
urethra. The spongy body dilates toward the extremity to 
form the glans penis. It dilates in the opposite direction, 
and thus forms a thick reflexion, round and prominent, 
which constitutes the bulb. The bulb is, in a way, ap- 
pended to the interior wall of the urethra; it is covered 
over by the bulbo- cavernous muscle which keeps it fixed 
at this point. Its posterior extremity is, so to speak, shut 
in by the median perineal aponeurosis which separates it 
from the membranous region of the urethra. 

In the angle formed by the jutting out of the mem- 



ANATOMY OF THE URETHRA 13 

branous portion are found Mery's or Cowper's glands which 
are likewise encased in the perineal aponeurosis. 

These are the chief anatomical details of which we stand 
in need in order to understand the nature and treatment of 
chronic urethritis. For the other details which concern the 
length, the direction, the situation, and the bearings of the 
urethra, we refer readers to works on anatomy, especially 
for descriptions of the relations of the membranous por- 
tion at the point where it pierces the ligament of Carcas- 
soune and the prostate. 

The internal surface of the canal is not even or smooth. 
The mucous membrane, excepting in a state of complete 
tension, is doubled up and forms in the whole extent of the 
canal a series of longitudinal folds, more or less numerous 
and variously developed, which may be distinguished by 
means of the urethroscope, and about which we shall have 
more to say later on. There exist, besides, certain trans- 
verse folds which permit the mucous membrane to stretch 
out during erection. 

The mucous membrane presents in its entire length 
papilla, which are especially abundant in the region of the 
fossa navicularis. Finally, we observe upon its surface a 
large number of openings (orifices). 

1. These are, first of all, small culs-de-sac [MorgagnV s 
lacunce) penetrating obliquely from before backward in the 
mucous membrane, and which are at times 0.01 millimeter 
deep (Beaunis and Bouchard). They are met with nearly 
exclusively in the superior wall of the canal (spongy re- 
gion). Their dimensions vary. The largest are found 
along the median line and will admit the head of a pin. 
Their number varies greatly, there being at times as many 
as twelve. By reason of their oblique direction in the 
thickness of the tissue, their upper wall forms a sort of 
valve. The most developed of these valves, the valve of 
Gtierin, is situated at about 0.015 millimeter from the mea- 
tus. The cul-de-sac which it forms measures 0.004 to 0.006 



14 CHRONIC URETHRITIS 

millimeter. Its importance and the obstacle with which 
it may oppose catheterization have been greatly exaggera- 
ted. It suffices to follow the floor of the canal in order 
to escape it. The lacunae of Morgagni do not secrete any 
fluid. 

2. Closed follicles which have 0.0001 millimeter di- 
ameter; they are situated immediately beneath the epithe- 
lium, and are considered as rudimentary glands of Littre. 

3. The glands of Littre are found scattered in large 
numbers throughout the whole length of the canal from 
the meatus to the bladder. They are encountered in great 
abundance upon the roof where their orifices form a closely 
aggregated dotting. The glandular body is rudimentary 
in the membranous and prostatic urethra. It is most de- 
veloped in the roof of the spongy portion. Their situation 
as to depth varies somewhat : at times the gland is found 
immediately beneath the epithelium, again it is placed 
deeply in the mucosa, and penetrates even between the 
trabecular of the spongy bodies. The excretory duct, con- 
sequently, varies in length from a few millimeters to two 
and even three centimeters and, exceptionally, it is found 
still longer. Generally it is rectilinear with oblique direc- 
tion toward the meatus. This direction is the more oblique 
the more we have to do with the larger glands and those 
nearest the meatus (Reliquet and Guepin). They open 
now on the surface of the mucous membrane, again in the 
cavity of Morgagni' s lacuna?. The glands of Littre are 
conglomerate glands which secrete a mucus destined to 
lubricate the walls of the canal. 

4. Prostatic follicles, Menfs or Coivper's glands, also 
open on the surface of the urethra. But the inflammation 
of these glands constitutes a special complication of ure- 
thritis, and we again, for this reason, refer to the special 
works on the subject for their study. 

In the prostatic region the mucous membrane forms a 
sort of crest, which is the verumontanum . It is made 



Vertex___ Peritoneum 



Uret 



Corpus 



Fundus 

Openings of the 
prostatic vesicles 



Pars prostatica 

Pars membranacea 
Pars bulbosa 



Opening of the 
prostatic ducts 



Muse, compressor 
urethral 



Opening of the 
glands of Cowper 



Septum penis 
Pars cavernosa 
Trabeculce 



Glans pen 




Mtiscularis 
(Detrusor) 

Mucosa 
rifice of the Ureter 

Jfuscularis 



Colliculus seminal 
Opening's of the 
ejaculatory ducts 



Corp. cavern, 
urethras 



Cor j). cavern, 
penis 



Tunica albug. 
Proeputium 



Orific. cutan 



Pig. 3 Longitudinal Section of thk Penis, Urethra, and Bladder 
Showing the relations of the parts as looked at from above. (After C. Heitzmann.) 



16 CHRONIC URETHRITIS 

up thus : The external angle of the trigone of Lieutand 
(bladder) enters into the first part of the prostatic portion, 
which is somewhat broadened and extends over the floor 
in the form of a quite long but slightly prominent fold. 
This delicate reduplication is puckered up at one point of 
its course and forms a more considerable eminence, which 
is the verumontanum (colliculus seminalis, caput gallina- 
ginis). The verumontanum generally contains, on the 
right and left, the orifices of the ejaculatory ducts; in the 
center is found a small depression, which is the prostatic 
utriculei Upon both sides the mucous membrane is 
pierced with punctiform openings, which are the excretory 
orifices of the prostatic follicles (Fig. 3). 



CHAPTER II 
THE GONOCOCCUS 

The gonococcus is the specific micro-organism of 
gonorrhea. Its existence was long suspected by authors 
who could not admit that clap was a simple, innocent in- 
flammation, but who would make of it rather a special 
virulent and contagious disease. 

It was Neisser who, while assistant at the Dermato- 
logical Clinic in Breslau, in 1879, discovered the true 
pathogenic agent of gonorrhea, gave to it the name which 
it has since kept, and demonstrated its presence in all 
instances of gonorrhea, both urethral and ocular. His 
results, at first strenuously contested, were confirmed quite 
soon by a host of authors. At the present day works upon 
the subject exist in abundance. 

When we examine a drop of fresh pus from a case of 
acute gonorrhea under the microscope, without previous 
manipulation, we distinguish within the leucocytes minute 
refractive bodies, collected in groups, quite distinct from 
protoplasmic granulations, and generally endowed with 
movements of oscillation and rotation. These are the 
gonococci. In order to study the morphologic details of 
the gonococcus it must be stained. 

I. Preparation and Staining. — The gonococcus pos- 
sesses a marked affinity for basic anilin colors. The 
violets especially (methyl -violet, gentian, dahlia) stain it 
directly and without mordant, as well as rapidly and with- 
out the aid of heat. Fuchsin, either the simple or carbo- 
lated solution (Ziehl's solution), is an equally good stain. 
Methylene -blue, although less energetic, is, however, the 

B (17) 



18 CHRONIC URETHRITIS 

reagent of choice, because it permits, in an admirable 
manner, of differentiation of the various elements in the 
preparation, the cellular protoplasms being scarcely tinted 
and the nuclei being clearly outlined, while the gonococci, 
of a blue more pronounced than that of the nucleus, pre- 
sent a very clear shape. 

On the contrary, the acid anilin stains (eosin), and 
hematoxylin only feebly impregnate the gonococcus and 
give to the whole preparation a uniform color. If the 
gonococcus is easily stained it is decolorized quite as readily 
under the influence of alcohol, acids, essences, and by all 
the usual decolorizers. These three properties which we 
have just enumerated — strong affinity for basic colors, 
feeble affinity for acid colors, and rapid decolorization by 
alcohol — form the basis of all procedures in the prepara- 
tion of specimens of the gonococcus. 

Simple Staining. — The following is the plan which seems 
most practical: 

1. The pus to be examined is spread out upon a slide, 
dried, and fixed in the flame of an alcohol lamp. 

2. A drop of methylene blue is placed upon the prep- 
aration (Kuhne's carbolated blue, Lcefler's solution). 

3. Wash immediately, dry, and examine without cover- 
glass by placing the immersion oil directly upon the 
preparation . 

Double Staining. — This is not for general use, simple 
staining generally giving quite satisfactory results. It has 
for its object the coloring of the microbes in a different 
manner from the neighboring tissues. Combined with the 
decolorization by the Gram method, it permits, in ninety - 
five per cent of instances, the establishment of a positive 
diagnosis. 

[If a double stain is desired, we recommend the follow- 
ing, which gives excellent results and is easily carried out. 
It is known as Lanz's method: A saturated solution of 
fuchsin and thionin in a two per cent aqueous carbolic 



THE GONOCOCCCTS 19 

solution are mixed in the proportion of 1 to 4. The speci- 
men is stained with it for half a minute, and then rinsed 
with water. The gonococci appear blue, the protoplasm of 
the pus-cells red, the nuclei bluish red, epithelia deep red, 
and their nuclei reddish blue.] 

The following" is Steinschneider's procedure: 

1. The pus is spread upon a cover-glass, dried, and 
fixed by the flame. 

2. The cover- glass is placed for two or three minutes 
in a saturated solution of anilin gentian violet. 

3. The decoloration is carried out for one minute's time 
in the iodo-iodid solution. (Iodin 1, iodid of potassium 3, 
distilled water, 300.) 

4. Wash with alcohol until the latter is no longer 
stained by the violet. 

5. Color with Bismarck brown. 

The gonococci are brown, the other diplococci blue. 

Staining of Sections. — (Wertheim.) To color, cut the 
section after fixation in alcohol and imbedding in celloidin. 
Wertheim employs the following method: 

1. The section is left for from three to five minutes in 
anilin gentian violet. 

2. Wash and place for one minute in lugol solution. 

3. Decolorize in ninety-five percent alcohol; the sec- 
tiou should retain a distinct violet color. 

4. Place for some minutes in an aqueous solution of 
methylene blue. 

5. Wash with water, dehydrate with absolute alcohol, 
clear up with essential oil, and mount in balsam. 

[One of the latest devices for examining for gonococci 
in sections of tissues is given by Finger, (CentraJblatt fiir 
die Krankheiten den Ram und Sexual Organe, Vol. V, 
Xo. 7), as follows: 

Put the section into borax -methylene blue (borax 5, 
methylene blue 5, water 100), for five minutes. Decolorize 
for one to two minutes in acetic acid one -half of one per 



20 CHRONIC URETHRITIS 

cent strong, wash in absolute alcohol, and mount in 
balsam.] 

[We append here some of the details of the staining 
process for those not well versed in the methods, who 
may like to avail themselves of a more minute guide. 

The glans penis is cleansed by a cotton pledget soaked 
in a bichloride solution, 1 to 1000. 

A platina loop mounted on a glass rod is then field 
in the flame of an alcohol lamp or Bunsen burner until 
it turns cherry red, and then withdrawn and allowed 
to cool. The loop thus sterilized is then introduced 
into the urethra by gently gliding down through the fossa 
naviculars and a little beyond. The little secretion thus 
obtained is placed on a clean slide and spread out on 
it with the aid of the platina loop. A much more even 
distribution and a thinner film is obtained by pressing 
another slide on the top of the first one and sliding them 
upon each other, without separating them. We have thus 
obtained two specimens for control examinations. The 
specimens are now allowed to dry in the air for ten min- 
utes. If in a hurry they may be dried over the alcohol 
flame, but the first way is the better one. 

The next step is the fixation of the specimen by pass- 
ing it, with the film side downward, three times rapidly 
through the flame. This procedure has a two-fold aim. 
It turns the albuminous parts of the specimen into insol- 
uble albuminates which otherwise would become blurred 
under the disintegrating influence of the staining fluid. 
On the other hand it arrests the movements of the bac- 
teria and makes observation easier. 

Now follows the second part, the staining of the speci- 
men. Among the many staining devices we will only 
mention those that combine excellent staining power with 
easiness in execution. The simplest and best method for 
ordinary staining is by a saturated aqueous solution of 
methylene blue. Of this a drop or two is placed on the 



THE GOXOCOCCUS 21 

specimen and left there from a half to one minute. It is 
then rinsed with distilled water by means of an irrigator 
until the water runs off unstained. The slide is then 
placed for a few seconds on its edge upon filter paper. 
This drains off the superfluous water. It is now laid 
down flat and blotted until dry. By holding the slide, 
film upward, over the flame of a spirit lamp for a few 
seconds, we can promote quick drying. 

The third and final step consists of placing a drop of 
immersion oil directly on the specimen without using a 
cover- glass. It is now ready to be put under the immer- 
sion lens of the microscope, and to be examined. 

A good bacterial microscope should be provided with 
an oil immersion lens tV, an Abbe condenser, and an iris 
diaphragm . 

If a permanent specimen is desired, a drop of Canada 
balsam (obtainable in collapsible tin tubes) is put on the 
film, a cover-glass is pressed down upon it, driving out 
the air -bubbles. An excess of the balsam will accumulate 
alongside the edges of the cover- glass, which soon hardens, 
walling in, as it were, the preparation in an air-tight 
encasement. A drop of immersion oil is now placed on 
top of the cover -glass, and the specimen is ready for 
examination. 

This staining with methylene blue is accomplished in a 
very little time, the whole process being finished in a few 
minutes, and gives excellent results. Although only a 
single stain is used, it is practically a differential stain, 
inasmuch as the gonococci appear deep blue, while the 
polynuclear pus -cells and epithelial cells take up a lighter 
blue color. The gonococci are found in masses either free 
outside of the pus -cells as if expelled by their having rup- 
tured the protoplasm, and appearing in groups around the 
boundaries of the destroyed pus -cells, or they may be seen 
in part within the pus -cells and sometimes upon the epi- 
thelial cells. As the purulent process progresses, the cellu- 



22 CHRONIC URETHRITIS 

lar constituents diminish, pus -cells prevail with intra- and 
extracellular gonococci in profusion. Toward the termi- 
nation of the process we see these get scarcer, transition 
(uninuclear) epithelium cells appear in numbers, and a few 
hyaline "iodophile" epithelium cells (which stain rapidly 
with weak solution of iodin) also. 

The gonococcus belongs to that class of bacteria which 
do not stain with iodin. This peculiarity is used to estab- 
lish, in a negative way, the identity of the gonococcus from 
the other diplococci which inhabit the normal as well as 
the diseased urethra. These latter microbes are stained by 
iodin and are thus distinguished from gonococci, while the 
gonococci are decolorized by iodin, and consequently will 
no longer appear in the field. If, therefore, there is the 
slightest suspicion that the diplococci brought out by the 
simple methylene blue staining process may not be the real 
gonococci, we will have recourse to the controlling iodin 
staining, known as Grain's method. One of the main in- 
gredients of Gram's stain is an anilin- water gentian violet 
solution, devised by Koch-Ehrlich, which, however, does 
not keep well when made in bulk and soon loses its stain- 
ing power. It is therefore always advisable to prepare it 
fresh. Heiman, New York, gives the following detailed 
working formula, which every practitioner can carry out : 

" To ten cubic centimeters of water add two cubic centi- 
meters of anilin oil, shake well, and filter through moist fil- 
ter-paper. To the clear anilin water obtained, add one cubic 
centimeter of ninety -seven per cent alcohol and one cubic 
centimeter of a concentrated alcoholic gentian violet solu- 
tion. This is about the quantity required for ordinary 
staining. After passing the cover- glass quickly through 
the flame, it is then placed in this solution from tw T o to 
three minutes. Gram next advises that the cover -glass 
may be washed in alcohol or not. I preferred to drain 
off the excess on filter -paper without washing in alcohol. 
The cover -glass is then placed for five minutes in Gram's 



THE GONOCOCeUS 23 

iodin solution, which consists of iodin, 1 part ; iodid of 
potash, 2 parts ; water 300 parts, and then placed directly 
into alcohol (97 per cent) in order to wash out all the 
coloring matter. It is sometimes advisable to renew the 
alcohol. Now wash the cover- g'lass well in water and 
place it in a Bismarck brown solution, which consists of 
a concentrated aqueous Bismarck brown solution, 1 part, 
water, 5 parts, for one or two minutes, then wash in water 
and mount in balsam. For differential stain, instead of 
Bismarck brown I have employed fuchsin and safranin, 
only to find that the Bismarck brown gave the best results. 
It is to be regretted that we have not at present a specific 
stain for the gonococcus, as we have for the tubercle 
bacillus. " 

The main cause of the unsatisfactory results in employ- 
ing Gram's method was due to washing the specimen with 
water between the two staining processes. Only the use of 
absolute alcohol in the preparation of the stains as well as 
for decoloration purposes insures successful results. The 
use of the two and one-half per cent carbolated water 
gentian violet solution of E. Fraenkel (ten parts of satur- 
ated alcoholic solution of gentian violet to ninety parts of 
two per cent carbolated water) is just as desirable as 
Ehrlich's anilin- gentian violet and more durable. Weinrich 
recommends to prepare the Bismarck brown in the follow- 
ing way: Hot distilled water, 70; Bismarck brown, 3; 
alcohol (96 per cent), 30; to be used when cold. As 
another counter- stain, Victoria blue is recommended (1 
part of a saturated solution of Victoria blue to 100 parts of 
water). The specimen may now be washed with water, 
and also after it has been decolorized with alcohol, but 
never before Gram's solution is applied.] 

II. Morphological Features. — In specimens stained 
by the processes which we have just described, the gono- 
coccus appears in the form of an ovoid diplococcus, more 
deeply stained than the neighboring tissues. It is made 



24 CHRONIC URETHRITIS 

up of two portions separated by a clear line. Each of 
these portions has the form of a bean with its concave 
surface to that of its fellow. The whole appearance is 
suggestive of certain small rolls called in Germany 
"Semmel." 

The dimensions of the pair are quite variable. The 
larger individuals divide transversely and thus give rise to 
a new pair. Bumm gives the following figures, obtained 
by means of a Zeiss tV objective and a micrometric ocular, 
in examiuing cover-glasses slightly stained w T ith fuchsin. 

Large individuals: Length from pole to pole, 1.6 p ; 
medium width, 0.8 /*. 

Small individuals : Length from pole to pole, 0.8 /* ; 
medium width, 0.6 /*. 

The fissure which separates the two individuals makes a 
part of a clear zone surrounding the elements, w T hich has 
given rise to the belief in the existence of an amorphous 
capsule not colored by the reagents. This interpretation 
of the appearances is contested. 

The grouping of the gonococci in heaps is character- 
istic. It results from the disposition of the pair of gono- 
cocci, each individual of which subdivides in turn to form 
a new T couple. Hence the groups, in which the individuals 
are not pressed together in clusters like staphylococci, nor 
disposed in chains like the streptococci. It results, also, 
from this division, that the number of individuals always 
remains even and often forms a multiple of four. 

The intracellular situation of the gonococcus when it 
finds itself in the pus, is one of its most important charac- 
teristics. It is encountered in leucocytes which are at 
times literally filled out to the point of bursting. These 
leucocytes are found alongside of others which have re- 
mained healthy. The nucleus is never invaded by the 
gonococcus. From this intracellular multiplication the 
typical form of rounded groups results, which are seen in 
the pus when the cell -wall ruptures. We find them in 



THE GOXOCOCCUS 25 

the specimens as groups surrounding a nucleus without a 
cellular contour being appreciable. The presence of gono- 
cocci in the leucocytes seems to be due to a phenomenon 
of phagocytosis. Epithelial cells are often covered over 
with groups of gonococci ; in sections of tissue they are 
sometimes found in the interior of endothelial cells capable 
of phagocytosis. 

III. Cultures. — Since the time when Neisser dis- 
covered the gonococcus, numerous experimenters have 
attempted to cultivate it. Bumm was the first to obtain 
positively certain results. He inoculated human serum, 
and it was upon this medium that he was able to cause 
pure cultures to develop which could be inoculated in 
man. Since this time innumerable attempts have been 
made with culture media of the most variable nature. 
Human serum mixed with agar constitutes, at the present 
time, the practical medium for the culture of the gono- 
coccus. This micro-organism either does not grow at all 
or grows poorly on ordinary media. 

[Recent experiments have proven that the gonococcus 
does not grow on ordinary media. It requires a neutral 
or slightly alkaline medium. Heiman particularly warns 
experimenters not to put the inoculated culture tubes in the 
ice chest as the gonococcus dies there quickly. He holds 
that the most favorable culture medium is liquid chest 
serum obtained from a serous pleuritic effusion, or hydro- 
cele serum in nutrient agar in the proportion of 1 to 3. 
The serum of course must undergo fractional sterilization 
from six to eight days, and after an interval of two or 
three days it should be sterilized again on three consecutive 
days.] 

We can not here give all the details of culture of the 
gonococcus, which, in practice, should be reserved for 
strictly special cases. We may say, however, that cul- 
tures of the gonococcus are distinguished by particular 
characters which render their confusion with other micro- 



26 CHRONIC URETHRITIS 

organisms difficult. They show little tendency to exuber- 
ance and die quickly. 

IV. Biology of Cultures.— The gonococcus requires 
an alkaline medium. It does not grow at ordinary tem- 
perature; the temperature most favorable seems to be about 
36° C. At 39° C. the colonies die within a few hours. 
Below 30° C. the colonies increase but little. At 20° C. 
the gonococcus does not die, but it never develops. Below 
18° C. it dies rapidly. Cultures, even when placed under 
the most favorable conditions die, in general, at the end of 
five or six days. They must be reinoculated every second 
day. 

[The longevity of the gonococcus without reinoculation 
has since been demonstrated. In the earlier experiments 
of Bumm a frequent transplantation was necessary owing 
to the fact that the culture medium — solidified placental 
blood -serum — was apt to dry quickly. Finger found it 
living on the twenty -ninth day upon a sealed beef- serum 
agar tube. Heiman found it on liquid serum plus nutri- 
ent broth on the ninety -third day, and on pus -smeared 
linen he demonstrated its presence on cover -glass prepara- 
tions on the sixty -sixth day, by the aid of a drop of steril- 
ized water.] 

The gonococcus is extremely sensitive to dessication. 
Various authors have tried the action of antiseptics. Solu- 
tions of silver are the most efficacious, ichthyol following 
them closely. But this action upon cultures has no great 
importance from a therapeutic standpoint; the mucous 
membrane furnishes indeed a medium infinitely superior 
to artificial media, and the gonococcus, hidden in the depth 
of the tissues, is protected against destructive agents. In 
the pus the gonococcus is more resistant, and it has been 
shown that in stains upon linen it retains its injurious 
properties for a long time ; a fact of importance in hygiene 
and legal medicine. As to the toxins secreted by the 
gonococcus, we have scarcely any data upon their nature, or 



THE GONOCOCCUS 27 

even regarding* their existence, although certain gonorrheal 
accidents in man have a decidedly toxic aspect. 

[Recent studies of the nature of the gonococcus have 
shown that it is not only an intracellular and epithelial 
parasite capable of producing only local and superficial 
changes in the mucosa, but that it may invade the submu- 
cous and subcutaneous connective tissue, giving rise to 
suppuration and even to subcutaneous abscesses. Again it 
maybe carried by the blood-and lymph-channels to remote 
regions of the body, causing metastasis in the peritoneum, 
pleura, endo- and myocardium, and painful affections of 
the joints. These latter are well known as gonorrheal 
rheumatism, as inflammation of the synovia of joints, and 
of the sheaths of tendons as tendo- synovitis. But. well 
known as these facts are, it has puzzled us to find no 
gonococci in some of these metastases, although they were 
in causal connection with the gonorrheal process. Was- 
sermann has shown that gonococci produce toxins, that is, 
products of their metabolism. These toxins are contained 
in the gonococci cadavers. Schaffer has injected those tox- 
ins into the human urethra, causing thereby a catarrhal 
urethritis of three days' duration with no sequelae. Scholtz 
defines these toxins as bacterio- proteins which are retained 
in the substance of the live gonococci. It can be isolated 
by filtration after death of the culture, and when injected 
in the urethra causes an urethritis of short duration, like 
that caused by toxins contained in the gonococcus cadav- 
ers. It may be inferred that these toxins are the cause of 
such metastasic processes, where painstaking cover- glass 
and culture examinations do not reveal the presence of 
gonococci. The toxins in such a case might have been set 
free by the dissolution of the germs.] 

V. Inoculations. — It is experimentally demonstrated 
at the present day in an irrefutable manner that the gono- 
coccus alone is sufficient to cause a typical urethral blen- 
norrhagfia in man. 



28 CHRONIC URETHRITIS 

Attempts to inoculate gonorrhea in animals have given 
no results. Injected, even in man, into the subcutaneous 
cellular tissue, it is but slightly injurious and disappears 
rapidly without causing suppuration. 

[The injection of emulsions of gonococei or of pure 
cultures into the peritoneal cavities, veins, or in the joints 
of white mice, rabbits, or guinea pigs, has caused inflam- 
mation of the cavities so treated, with rise of temperature 
and loss of weight. Attempts to inoculate the different 
mucous membranes with the virus have proved futile. 
The gonococcus, therefore, introduced in animals acts in 
a toxic and not in an infectious way.] 

VI. Clinical Study of the Gonococcus. — When the 
gonococcus is introduced into the male urethra it does not 
find an absolutely sterile field. The anterior urethra is, 
on the contrary, normally inhabited by a numerous mi- 
crobic flora, especially in the neighborhood of the meatus, 
where a large number of micro-organisms are to be found. 
These microbes are not habitually pathogenic, but their 
virulence may at certain times be increased, and they may 
then play an important role in urinary pathology. 

In a health} 7 urethra the gonococcus never exists. We 
may here find diplococci which present certain analogies of 
form. But the form, the dimensions, the grouping, the in- 
tracellular situation of the gonococcus, and especially its 
properties of being decolorized by Gram's method, are 
distinctly characteristic. As soon as the gonococcus is 
implanted at a given point of the mucous membrane, it 
develops there, multiplies, and provokes a reaction in the 
tissues which constitutes the blennorrhagia or gonorrhea. 
It then spreads on the one hand by gaining access to a 
surface, more or less extensive, of the urethral mucosa 
and of the mucous membranes with which it is continuous; 
on the other hand by penetrating more or less deeply into 
the depth of the tissues. 

An attempt has been made to study the manner in 



THE GONOCOCCUS 29 

which the gonococcus behaves in regard to the epithelium 
and connective tissues. 

Epithelium. — The course of the gonococcus in the epi- 
thelium of the mucous membranes has been studied by 
Bumm, Orcel, Touton, Jadassohn, Finger, and others. 

Bumm has shown that the gonococcus rapidly traverses 
the epithelium of the conjunctiva. According to this 
author, it does not ordinarily penetrate other than the cylin- 
drical epithelium, never the resistant pavement epithelium, 
and but to slight extent the connective tissue. 

Touton, Jadassohn, Fabry, Dinkier, and Rosinsky have 
shown that the gonococcus multiplies on the surface of the 
pavement cells, only penetrating between the most superfi- 
cial without reaching the deep layers or the mucosa. 

Finger has demonstrated by autopsy made after experi- 
mental inoculation, that the gonococci begin by prolifer- 
ating on the surface of the epithelium where they are 
united in small groups. Then, at the end of thirty -six 
hours, they glide in between the superficial cells at the 
points which present the least resistance. They rapidly 
invade the lumen of Morgagni's lacunae, where they are 
found free upon the surface of the epithelium. Diapedesis 
begins, the leucocytes gain the surface of the mucous 
membrane, and gonococci are already found within the 
leucocytes. 

Changes in the epithelium depend upon the nature of 
the latter. The gonococci scarcely penefrate into the 
stratified pavement epithelium, and the leucocytes encased 
between the cells contain none. 

In the cylindrical epithelium they are especially abun- 
dant in the neighborhood of the glands, where they fill up 
the pus -cells and pass through the epithelial layer in long 
thread-like chains ; the same is true of the walls and of 
the stratified epithelium of the bottom of the lacunae where 
they are, however, much less abundant. Finally, they 
are again found in the excretory ducts of the glands, but 



30 CHRONIC URETHRITIS 

they are never seen to insinuate themselves between the 
secreting cells. 

We thus see that the gonococcus penetrates, by prefer- 
ence, the cylindrical epithelium of the urethra, especially in 
the vicinity of the glands. If the pavement epithelium 
does not oifer it an absolute obstacle, it at least opposes a 
marked resistance. 

Connective tissue. — Bumm has shown that, in ocular 
blennorrhagia (opthalmo- gonorrhea), the gonococcus in- 
vades the connective tissue to a slight degree only. 

Touton (1889), Jadassohn, Neisser, and others think 
that it never reaches this tissue. Frisch, however, in two 
instances of rectal blennorrhagia found the gonococcus in 
the glands and interglandular tissue. Wertheim has seen 
it penetrate through the tubes and the peritoneum ; Pel- 
lizari has observed it in periurethral abscess ; Horwitz 
demonstrated its presence in pure cultures in an abscess 
of the hand. Finally Crippa found it in edema of the 
prepuce coming on eight days after infection. 

To sum up, the gonococcus is a microbe of the mucosa, 
its habitat of preference is the cylindrical epithelium, but 
it may also penetrate the other varieties of epithelium and 
even reach the connective tissue. In the latter case it be- 
comes but mildly pyogenic. 

VII. Extension and Generalization.— 1. The gono- 
coccus may develop primarily on the surface of the urethral, 
the conjunctival, the vaginal, or the rectal mucous mem- 
branes. We, likewise, observe in the new-born, instances 
of blennorrhagic stomatitis and rhinitis. 

Finally, it may spread by direct propagation to the whole 
extent of the genital and urinary organs of the male and 
of the female (urethritis, cystitis, pyelitis, nephritis, Cow- 
peritis, prostatitis, spermato- cystitis, epididymitis, vagini- 
tis, vulvitis, Bartholinitis, metritis, salpingitis, ovaritis, 
peritonitis ) . 

2. The gonococcus can also penetrate into the blood- 



THE GONOCOCCUS 31 

current and set up special inflammatory disturbances in 
organs far away from its point of entrance. These com- 
plications of gonorrhea have been observed in the endo- 
cardium and in the articular and visceral serous membranes. 
Certain neurites and myelites have likewise been attributed 
to the influence of the same micro-organism. 

VIII. Persistence and Increase.— In the internal 
organs and in the articular and visceral serous membranes, 
the gonococcus generally disappears rapidly; perhaps by 
reason of the fever which it has caused,- and to which it 
can offer no adequate resistance. Upon the mucosa, on the 
contrary, it shows a marked tendency to establish a domi- 
cile and to persist for a long period in a latent state in 
giving rise to chronic manifestations. It is difficult to 
establish accurately the role of the gonococcus and its 
ultimate fate in chronic urethitis. They have been found 
still to persist at the end of six years and even longer. It 
seems that under these conditions, after a lengthy period 
of reproduction upon the same soil, their virulence becomes 
attenuated, so that they no longer provoke any but slow 
reactions of chronic nature in the tissues. They can thus 
remain indefinitely in the surface of the mucous membrane 
and in the orifices of the glands. 

However, when they have reached this state of viru- 
lence, in a measure latent, they may, under the influence 
of some irritating cause, readily start up a fresh growth 
upon this same soil, and reproduce an acute recurrence. 
Furthermore, if transported upon another mucous mem- 
brane, whether it be in the same individual or in another 
subject, they are capable of here developing afresh an acute 
gonorrhea with all its consequences. 

[Cushing (Bulletin of the Johns Hopkins Hospital, 1899, 
p. 75), reports two cases of acute diffuse gonococcus peri- 
tonitis in two women where the gonococcus was found in 
the exudate on performing laparotomy. Examination of 
the vaginal and urethral discharge was negative. In each 



32 CHRONIC URETHRITIS 

case the peritonitis developed daring menstruation, follow- 
ing an exposure to infection. Cover- glass examination 
showed the presence of gonococci, and cultures developed 
diplococci which were decolorized by the Gram method. 
Before we understood the role played by the toxin of the 
gonococcus, such inflammations had been regarded as 
the result of mixed infections, as no gonococci could be 
found in the exudate. These cases seem to establish for 
the first time convincing evidence of a peritonitis caused 
by the gonococcus. 

It seems significant and interesting, from an etiologic 
standpoint, that these two reported cases happened during 
the time of menstruation. This will recall to the mind of 
the practitioner such cases of peritonitis in the puerperal 
state where, in spite of the most minute asepsis and an 
uneventful delivery, septic peritonitis has set in. Likewise 
cases of para- and perimetritis will be remembered that 
have started with the onset of menstruation and have been 
attributed to taking cold, to a strain, and to other such 
unproven incidents. There was always, and there is yet, a 
suspicion in critical minds concerning the origin of these 
exudative pelvic inflammations. In the light of the ubiqui- 
tousness of the gonococcus, and the obscure and circuitous 
ways of its acquisition, it is perhaps not too hazardous to 
maintain that a goodly part of ascending pelvic inflamma- 
tions, unrecognized as to their etiology, are due to gono- 
coccal infection, either by the coccus itself, or by its 
toxins. The puerperal and menstrual states, with their 
attendant congestive conditions, might create an especially 
receptive medium for the propagation and invasion of 
dormant or, as the case may be, of a recent and active 
brood of gonococci. Furthermore, the life -history of the 
gonococcus is of such a retributive character that it stops 
short at nothing. A man affected with chronic gonorrhea 
of a form so slight as to be unconscious of its presence, 
may become refractory to his own gonococci. But trans- 



THE GONOCOCCUS 33 

planted to a new soil they will become virulent in the 
vaginal mucosa of their new host. By this implantation 
on a new culture -medium, the gonococci may again assume 
a degree of virulency which, in turn, is capable of infect- 
ing the man who bore ancestors of such gonococci with 
immunity. By some as yet unknown biologic transforma- 
tion they become alien to the soil they have inhabited 
before with immunity to its bearer. It is evident, there- 
fore, that a woman with an exudative para- or perimetritis, 
acquired from a latent chronic gonorrhea of a man, may 
be able, after sexual relations have been resumed, to infect 
that man with just as virulent a type of gonorrhea as if 
acquired by any impure illegitimate intercourse. Such a 
condition may become embarrassing to matrimonial life 
from a moral and legal standpoint. The physician who is 
well acquainted with all these possibilities of gonococcus 
life, will be able to explain and to redeem a seemingly lost 
reputation.] 

Thus it is of the highest importance to determine the 
moment when gonococci have disappeared from the ure- 
thra. Unfortunately they are found only in an inconstant 
manner in chronic gonorrhea, whose morbid products 
(secretitious urinary filaments) may contain none, while 
they may persist in the chronic lesions. Certain lesions 
may even produce no secretion. Therefore, one cannot 
jump at the conclusion that the gonococci have disap- 
peared. When a series of microscopical researches, con- 
scientiously carried out, have failed to show any trace, we 
may see a recurrence take place under the influence of 
some ordinary cause, and the gonococci may at once show 
active development. 

Furthermore, the lesions of chronic urethris have a 
strong tendency to continue their evolution over a period 
of years, generally even, unless arrested, during the pa- 
tient's whole life. Undoubtedly, we may admit that, in 
certain cases, this tendency to keep up the irritation may 



34 CHRONIC URETHRITIS 

be due to external causes, even, for example, to inappro- 
priate treatment. Still we must not forget that this par- 
ticular tenacity of chronic urethritis, this tendency which 
the lesions possess of spreading out without cessation and 
invading neighboring areas, can scarcely be understood, 
unless we admit that gonococci, which have become almost 
inert, hidden in the depth of the tissues, continue to pro- 
voke in them a slow chronic reaction, but one sufficient to 
perpetuate the disease, and even to permit of its trans- 
mission . 

IX. Secondary Infections. — When the gonococcus 
invades the urethra we observe a more or less complete 
disappearance of the other micro-organisms which nor- 
mally inhabit it. These micro-organisms subsequently put 
in a reappearance as the gonococcus becomes weakened; 
but the changes in the urethra caused by the gonor- 
rhea create in it a sort of special receptivity for these 
microbes which, in general, are without influence upon the 
tissues. 

Thus are explained the instances of urethritis without 
gonococci, which are occasionally observed after coitus in 
cured gonorrheas, and which rapidly disappear under mild 
antiseptic treatment. 



CHAPTER III 
ACUTE URETHRITIS 

Cases in which a study of the pathological anatomy of 
acute urethritis has been possible are not' very numerous. 

We knew only of few autopsies which had been carried 
out upon those who had accidently died a few days after 
having contracted clap, up to the time that Finger 
practiced his experimental inoculations upon moribund 
subjects, making it thus possible for him to examine the 
urethral mucosa thirty -six to forty -eight hours after the 
onset of urethritis. 

Finally, the studies made by endoscopists, as well as the 
works of Touton, Xeelson, Brissaud, Segond, Wasserman, 
and Halle upon chronic urethritis, compared one with the 
other, permit us to understand in the following manner the 
anatomical evolution of gonorrhoic urethritis. 

The gonococcus implanted at a given point of the ure- 
thral mucous membrane develops, as we have already seen, 
in the epithelial layer, which it invades by continuity, 
multiplying in the neighboring cells situated upon the 
same plane and penetrating rapidly into the deeper epi- 
thelium. During this period no symptom is manifest; it 
is the period of incubation of the disease. 

Having thus arrived at the mucous membrane, it here 
sets up an inflammatory reaction absolutely similar to 
other inflammations; the vessels become turgescent, there 
is abundant diapedesis of leucocytes, production of em- 
bryonal cells, phagocytosis becomes established, and sup- 
puration begins. The epithelium, already altered by the 
first efforts of the parasite, is destroyed still further by the 

(35) 



36 CHRONIC URETHRITIS 

passage of the leucocytes, which become infiltrated in the 
interstices of the cells; it desquamates abundantly, and 
ends by disappearing in areas, leaving the mucous mem- 
brane exposed. In certain very acute cases this desquama- 
tion is so very rapid, and the inflammation of the deeper 
strata of the mucous membrane is so intense, that they give 
rise to the formation of false membrane. 

The submucosa itself, under the influence of inflamma- 
tion, gets abundantly infiltrated with embryonal cells. At 
times this infiltration is limited to the superficial layers of 
the mucous membrane, at other times it invades the whole 
thickness. The mucous membrane is then thick, friable, 
loses its elasticity, and bleeds readily. (Clap with chor- 
dee.) 

At times the inflammation goes even deeper and reaches 
the muscular layer and the spongy tissue; the sheaths of 
the corpora spongiosa swell up; extensive embryonal infil- 
trations are produced; the arteries present lesions of endo- 
periarteritis ; the veins, attacked with phlebitis, enclose 
here and there fibrinous coagula. The lymphatic vessels 
are likewise invaded; the inguinal glands swell up, become 
sensitive, and at times even suppurate. Finally the urethral 
glands participate actively in the inflammation. This 
participation is especially important because we find it 
playing a major part in chronic gonorrhea. The internal 
surface of their excretory canal becomes the seat of an 
abundant epithelial proliferation, while their walls thicken 
and undergo embryonal infiltration. It is especially about 
these glands that we find extension of the inflammation to 
the spongy bodies, and even to the cavernous tissue. 
The glandular inflammation results often in a sclerous re- 
traction, or in an obliteration of the excretory duct with 
formation of a cyst. These inflammatory phenomena are 
observed in the fossa navicularis where the infection is 
first of all established, and is propagated over a more or 
less considerable extent of the urethra, according to the 



ACUTE URETHRITIS 37 

virulence of the infection and the resistance of the subject. 
The inflammation thus extends up the whole length of the 
urethral mucous membrane, but its intensity decreases in 
proportion as we advance from the point at which inocula- 
tion has occurred, as is observed in all local infections. It 
naturally follows that gonorrhea may remain limited to 
that portion of the urethra situated in front of the external 
sphincter or, on the other hand, pass this sphincter and 
reach the posterior urethra. The observations carried out 
at the Xecker school have brought out in an excellent 
manner the clinical importance which this extension ac- 
quires in the posterior urethra. Once having reached 
this region, the symptoms change entirely, and the blen- 
norrhagia may continue its upward march, invading the 
bladder and kidneys, or the prostate, seminal vesicles, and 
epididymes. The invasion of the posterior urethra is thus 
a marked feature in the pathology of gonorrhea. 

What is the role here played by the external sphincter? 
Guyon attributes to it the power of arresting the march of 
urethritis, which should thus be localized anterior to it, 
else when it has passed it, it would find the way which 
leads to the various complications of the disease widely 
opened and without defense. However, if we note that 
the epithelium and the mucous membrane are continuous 
in the whole length of the urethra, we cannot attribute to 
a simple sphincter, however powerful it may be, the ability 
to arrest the course of so virulent an affection as that pro- 
duced by the gonococcus. It would seem rather that 
according to the degree of virulence of this infection and 
the resistance which the subject may oppose to it, the blen- 
norrhagia may spread to a more or less distant point, as 
all local infections do, and invade the urethra only in its 
more anterior portions or in its whole extent. 

Acute posterior urethritis should not, therefore, be con- 
sidered as a complication, as it is of quite frequent occur- 
rence. Finger finds it in fifty to eighty per cent of cases 



38 CHRONIC URETHRITIS 

(diagnosis by irrigation test). Jadassohn in sixty to sev- 
enty per cent of cases. Other authors give similar 
figures. 

At the end of a few weeks, moreover, especially under 
the influence of a rational treatment, the gonorrhea 
tends to retrogress. The gonococci diminish in numbers, 
the phenomena of phagocytosis becomes less intense, the 
embryonal infiltrations become, at least in part, resorbed, 
the vascular phenomena of inflammation diminish, and the 
epithelium which has been destroyed tends to become 
regenerated. 

But there is never restitution ad integrum, and the 
epithelium, notably, never again takes on its normal 
cylindrical form. Besides, the gonococcus hidden in the 
depth of the tissues and in the glandular cavities does 
not disappear completely in st) short a time, and its pres- 
ence within certain lesions, which persist, impresses upon 
the latter a special mark, and gives to them. a characteristic 
course which constitutes chronic gonorrhea. 



CHAPTER IV 
PATHOLOGICAL ANATOMY OF CHRONIC URETHRITIS 

The anatomo- pathological alterations of chronic ure- 
thritis, easily recognizable during life by means of the 
urethroscope, become, on the contrary, often invisible 
when they are sought for upon the cadaver. 

The phenomena of local congestion, the edema and the 
swelling, disappear after death; while the lesions which 
persist are generally so minute that it is difficult to 
recognize them with the naked eye. 

Bj* an attentive examination we may, however, discover 
a certain number of alterations in the mucosa and of the 
epithelium which we will now pass in review. 

On the surface of the epithelium we frequently note 
small, whitish plaques analogous to epidermic cicatrices, 
and which are due to a local thickening of the layer of 
epithelial cells (xerosis). We scarcely ever find those 
ulcerations or losses of substance which the older authors 
describe. Still quite frequently we meet small nodules of 
pin -head size, due to the obliteration and cystic trans- 
formation of the Morgagni lacunes and Littre's glands ; 
at other times these lacunes and glands have a largely 
gaping orifice, extending slightly above the level of the 
mucous membrane. 

The mucous membrane presents scarcely any altera- 
tions appreciable to the naked eye. The embryonal in- 
filtrations and even the lesions of sclerosis, so clear on 
microscopic examination, are not visible unless they are 
of excessive development (strictures). The existence of 
granulations is, however, made out when deep-seated in- 

i 39 ) 



40 CHRONIC URETHRITIS 

filtrations raise up the surface of the mucous membrane 
and give to it a dull aspect, or when numerous glandular 
lesions exist localized at a given point. 

In a word, the macroscopic examination of the urethra 
in the cadaver gives only vague and altogether insufficient 
information concerning the chronic inflammatory processes 
that the microscope can bring to light. 

On the other hand, the microscopical changes are ex- 
tremely interesting and their study is of the utmost 
importance. 

We shall examine successively the histologic changes 
of the epithelium, of the submucous tissue, of the lacunae, 
and of the glands of the urethra. 

The epithelium has a well-marked tendency to pass 
from the cj'lindrical to the flat and even horny variety of 
epithelium, and we may also find intermediary types be- 
tween these two extremes. The cells of the superficial 
layer begin separating and undergo mucous transforma- 
tion ; the cells situated immediately underneath pro- 
liferate and are strewn with numerous leucocytes. Little 
by little the transformation is effected. The superficial 
cylindrical cells become first cubic, then more and more 
flattened. According to Wassermann and Halle, the 
transformation into pavement epithelium may be quite 
clear without there being superficial cornification. We 
then find simply a superficial layer of flat cells reposing 
upon one or more layers of polygonal cells and one stratum 
of cubic cells. But generally the changes are more pro- 
nounced and the epithelial transformation is more complete. 

Neelssen, as well as Finger, believes that the nutrition 
of the epithelium is interfered with by the fibrous transfor- 
mation of the subjacent mucosa, while Baraban denies the 
importance of this factor. However this may be, most 
often the epithelium takes on the epidermic type described 
by Halle and Wassermann. We find a superficial layer of 
corneous cells reposing on a layer of lace -work -like poly- 



PATHOLOGICAL ANATOMY 41 

genial cells (Malpighian net-work). The lower stratum 
of cubic cells still persists. Finally all differentiation is 
lost. The epithelium, which lies now on a mucosa trans- 
formed into fibrous tissue, takes on the aspect of cica- 
tricial epithelium, and is made up solely of a few layers 
of fiat cells. These alterations are encountered in all the 
portions of the urethra. They are, however, more frequent 
in the anterior urethra. 

The mucous membrane presents the most important 
lesions. It is here that the real processes of chronic in- 
flammation which we are studying take place. The first 
phase of this process, at the time the acute form passes 
into the chronic, is characterized by the existence of a more 
or less abundant inflammatory infiltration of embryonal 
uninuclear cells, of pus -corpuscles, and of epitheloidal cells. 
This infiltration may be so abundant that the submucosa 
entirely disappears. Wassermaun and Halle have seen, at 
the posterior part of a stricture, a mucous surface deprived 
of epithelium, in which the mucosa was only a collection of 
small round cells with numerous capillaries of new forma- 
tion. 

Usually the infiltration is not so abundant; it is not 
generalized, but forms plaques of variable extent and 
depth, surrounding, by preference, the lacunae and the 
glands. It is accompanied by an abundant vasculariza- 
tion, due to the formation of new capillaries. It results 
from this that the surface takes on at certain points a 
granular aspect, sometimes forming papillae or veritable 
vegetations either simple or ramified. 

As in all chronic inflammatory processes, this embryonal 
infiltration is organized into fibrous tissue; it first becomes 
richer in fusiform cells, then little by little takes on the 
texture of true cicatricial tissue, the final stage of an evolu- 
tion of which all the intermediary steps are well recognized. 
Often in the same individual we find different forms united 
in a single area. 



42 CHRONIC URETHRITIS 

Iii the center cicatricial tissue, and then concentric, or 
at least successive zones in which the embryonic infiltra- 
tion is more and more marked. 

This appearance naturally indicates that the lesions at 
first bounded by circumscribed limits have a continual 
tendency to spread by new exacerbations and to invade, 
little by little, the healthy tissues. 

We have seen that the lesions are especially marked 
around the lacunae of Morgagni and the glands of Littre. 

The lacunce are only depressions in the mucous mem- 
brane, having the same structure as the latter and showing, 
in consequence, the same lesions. 

The infiltration of the perilacunar tissue by leucocytes, 
and the vascular dilatation which accompanies it, produce 
a swelling of the lacunae and a crater-like projection of 
their orifices. 

The consecutive fibrous transformation is shown in two 
ways: At one time the lacuna? retract, become atrophied 
and disappear; at another, on the contrary, the orifice 
becomes obstructed; they then fill up with cellular debris 
and are transformed into cysts which appear upon the 
surface of the mucous membrane in the form of whitish 
nodosities. Finally they may suppurate and give rise to 
periurethral abscess and subsequently to fistula; but this 
suppuration, which is quite frequent in acute urethritis, 
is rare in the chronic form. 

In regard to the glands of Littre, where we have seen 
the acute gonorrhoic process to be the most deeply marked, 
we again find in the chronic form analogous tendencies. 
Here, also, it is in the gland and in its immediate neighbor- 
hood that the lesions of infiltration are the most manifest. 

In the gland, the lesions may take on various forms: At 
one time the secretion is increased, and the gland swollen, 
at another, small cysts form and fill with colloid material, 
or the cellular proliferation, observed at the surface of the 
mucous membrane, reaches the acinus, undermines the 



PATHOLOGICAL ANATOMY 43 

cylindrical epithelial covering, insinuates itself between the 
latter and the basal membrane and destroys the acinus in 
filling the gland with epithelial debris. (Halle and Wasser- 
mann). At still other times the gland, choked by the 
retraction of the surrounding fibrous tissue, is slowly 
destroyed. 

Finally, just as in the case of the lacunae, it may be 
invaded in an acute attack, suppurate, and give rise to 
follicular abscess. As to the periurethral spongy tissue, it 
does not, in general, participate in the chronic inflamma- 
tory process; the Littre glands, however, which are found 
here, are invaded and form in the midst of the intact tis- 
sue small sclerotic nodules. 

It happens, however, that the erectile tissue becomes 
invaded by the same changes as the mucous membrane, and 
that a chronic periurethritis develops, passing through the 
same phases of round-cell infiltration, and then sclerosis, 
as the mucous membrane itself. These infiltrations, nearly 
always limited to small foci, are accompanied by endo- 
periarteritis of all degrees in the large arteries of the 
spongy body. The circulation is obstructed; the spongy 
spaces, compressed by the fibrous retraction, disappear, and 
there remains only a firm cicatrix, more or less extensive, 
encircling the urethra like a ferrule. The same lesions 
may also be encountered in the cavernous bodies where 
they are produced in the same way and go through their 
evolution in an identical manner. 

In the posterior region of the urethra the lesions are of 
the same nature and pursue a similar course. Here we 
found the same epithelial changes and the same modifica- 
tions of mucous membrane, small round-cell infiltration with 
tendency to fibrous organization; but these changes are, in 
general, less marked here than in the anterior urethra. 

Besides, we find here some special features which are 
due to the anatomical and physiological conditions peculiar 
to each region. 



44 CHRONIC URETHRITIS 

In the membranous region, the walls of the urethra, 
rendered rigid by sub-epithelial infiltrations and subjected 
to the energetic action of the sphincter muscles, split open 
or fissure, and we can frequently make out the existence of 
more or less deep rhagades with red, easily bleeding bases, 
cutting into the infiltrated tissue. These ulcerations, by 
reason of their subsequent cicatrization, are one of the 
most frequent causes of stricture. 

In the prostatic region acute urethritis is frequently 
accompanied by follicular abscesses which open into the 
canal of the urethra, and then cicatrize in giving rise to 
formation of small callosities. The infiltration of the 
verumontanum may terminate in the same manner, pro- 
ducing a dense fibrous tissue which changes the aspect of 
the mucous membrane. The callosities thus formed com- 
press and obliterate the ejaculatory ducts. The infiltra- 
tion extends along the ducts whose walls become rigid 
and gaping. The prostatic glandules are attacked in the 
same way as the glands of the anterior urethra, and become 
the seat of a mucous, muco- purulent, or simply purulent 
catarrh, or the periglandular infiltration brings about their 
necrosis and destruction. But these lesions of the ejacula- 
tory ducts and of the prostate are already outside of the 
category of simple chronic urethritis. Besides, the posterior 
region is poor in glands of Littre and does not possess the 
lacunas of Morgagni. 

This is the explanation of chronic urethritis in this 
region being less deep- seated, and consequently less tena- 
cious; when it persists, it does so because it is accompanied 
by prostatic lesions or some form of complication. 

To resume: When gonorrhea attacks the urethra it be- 
gins in the region of the meatus and invades the canal 
over a considerable extent, according to the resistance 
of the subject, the virulence of the disease, and the par- 
ticular circumstances which more or less favor extension. 

It produces, in the urethral tissues, an abundant eel- 



PATHOLOGICAL ANATOMY 45 

hilar infiltration. In the acute stage this infiltration is 
manifest by suppuration and discharge. In the chronic 
stage it tends to limit itself to circumscribed areas around 
the glands and lacuna?, to become organized into fibrous 
tissue. From this numerous lesions result. 

The epithelium flattens and tends successively to take 
on the structure of pavement epithelium, of epidermis, or 
of cicatrical horny tissue. 

The mucous membrane is especially invaded along the 
course of the diverticula and the glandular ducts which 
traverse it. It loses its elasticity, and then retracts in 
being transformed into firm fibrous tssue. 

The glands are attacked with mucous or purulent ca- 
tarrh. They may even become obliterated and give rise 
either to the formation of small cysts, or of abscesses, 
which open and cicatrize in leaving behind fibrous cal- 
losities. Finally they may become choked by the retrac- 
tion of fibrous tissue which surrounds it and disappear 
without leaving any traces. 

The periurethral tissues are only rarely attacked. They 
present the same alterations and also end by undergoing 
fibrous transformation. 



PART SECOND 

DIAGNOSIS 

Diagnosis of chronic urethritis is based upon: 

1. The symptoms of which the patient complains. 

2. The results furnished by the objective examination. 
The symptoms which attract the patient's attention 

are, in the first place, the suppuration, which shows itself 
under the form of a discharge, or of shreds in the urine, 
and then of functional disturbances and abnormal sen- 
sations, which are felt in the canal or in the neighboring 
organs. 

The objective examination of the canal includes the 
employment of palpation, of sounds, of uretlirometers, and 
of the urethroscope . 

The subjective symptoms necessarily vary very much 
according to the nature, the extent, and the seat of the 
lesions, and also according to the susceptibility of the pa- 
tient. In this respect there exists no fixed rule; while it 
frequently happens that the symptomatology is in direct 
line with anatomical lesions, that is to say, if the symp- 
toms of which the patient complains indicate quite accu- 
rately the true import of the changes present, we also 
frequently observe just the opposite. Benign lesions at 
times accompany very pronounced symptoms, while grave 
lesions, on the other hand, occasion but the slightest 
derangements, and they may even exist for a long time 
unnoticed. Therefore, while taking into account the s} T mp- 
toms which may be more or less freely described by the 
patient, the physician should never neglect to make a 
complete objective examination if he cares to arrive at 

(47) 



48 CHRONI.C URETHRITIS 

a knowledge of the actual existence of lesions, their nature, 
their location and their extent. [Diagnosis of chronic 
gonorrheal urethritis is made up like all diagnoses of 
different but convergent attributes. But nowhere does it 
carry the character of a composite picture with more right 
than here. The subacute, the latent form, or a recent 
exacerbation may, one or all, contribute to create a com- 
plexity of symptoms quite embarrassing at first; but, 
fortunately, we are enabled by the systematic use of the 
means at our disposal, which will be found elsewhere in 
this work, to locate and properly treat these affections.] 



CHAPTER V 

SUPPURATION 

Suppuration is the symptom most frequently observed; 
it is often the only one which preoccupies the patient, and 
oftentimes, also, the only one which disquiets the physician. 
We will see, however, that some forms of chronic urethitis 
exist in which we do not discover any apparent trace of 
discharge, at least for a very long time. 

I. The Quantity of Secretion furnished by chronic 
urethritis depends upon the nature and extent of the le- 
sions. When it is very abundant it causes a continuous 
oozing which is the more apparent the longer the patient 
refrains from urinating. The discharge is also consider- 
able in the morning, because of the period passed in 
sleep, and the genital congestion which results from pro- 
longed rest in bed. It shows at the meatus, either spon- 
taneously, or after pressing out the canal with the finger, 
as a drop, commonly known under the name of goutte 
militaire. This drop has a greenish-yellow, whitish, gray- 
ish, or clear color, according to the composition of the 
discharge. At other times the suppuration is not suffi- 
ciently abundant to produce a drop; the slight amount of 
secretion which appears at the meatus dries, agglutinates 
the borders of the canal and gives what is called the glued 
meatus. Finally, if the exudate is produced in too small a 
quantity to appear as an external discharge, and remains 
adherent at the point where it is formed, the first jet of 
urine detaches it and washes it out; it then appears under 
the form of threads (Tripperfaden) , more or less numer- 
ous, more or less thick and heavy, floating in the urine. 

D (49) 



50 CHRONIC URETHRITIS 

These filaments, according to their composition, are of 
variable aspect. At times, large and heavy, they soon fall 
to the bottom of the vessel; at others they float for a con- 
siderable time. They are thin and elongated, or small and 
short, fluffy or compact, or at times they may resemble 
minute shreds of cotton. Fiirbringer attributes to them a 
particular form — comma shape — when they come from the 
posterior urethra. 

The presence of the urinary filaments constitutes one of 
the most frequent symptoms observed, and one of the best 
known in chronic urethritis. 

We have already said that the suppuration is at times 
sufficiently abundant to form a veritable discharge; at other 
times, on the contrary, it shows in quantities so small that 
it is perceived only under the form of small flocculi which 
swim in the urine. In general, the suppuration diminishes 
according as the patient's condition improves; but chronic 
urethritis often presents acute exacerbations during which 
the discharge is seen to reappear; the course of the disease 
is thus marked by successive phases, during which suppura- 
tion increases or diminishes. Acute exacerbations are often 
attributed to excesses, at times to the effects of treatment, 
and they may even occur without known cause. When they 
are violent they constitute "relapses," and their symptoms 
become sufficiently intense to call to mind the acute period. 

II. Microscopically, the secretion of chronic urethritis 
comprises different elements associated in very variable 
proportions. These are mucus, epithelial cells, leucocytes, 
and microbes; one or more of these elements may be 
absent or, on the other hand, may predominate. 

a. Mucus comes from catarrh of the mucous membrane, 
from hypersecretion of glands in the diseased areas and, 
probably, also from the mucous degeneration of epithe- 
lium. It exists at times alone, forming a clear and limpid 
discharge, slightly viscous and sticky, and generally hold- 
ing in suspension other elements of the discharge. 



SUPPURATION 51 

b. Epithelial cells which have been divided into several 
groups : 

1. Large pavement epithelial cells, arising simply from 
desquamation of the superficial layers of the altered mu- 
cous membrane. 

2. Transition epithelial cells — round, oval, polygonal, 




Fig. 4. Secretion of Chronic Urethritis from "Morning Drop." 

M, mucus; E y epithelium; B, bacteria (streptococcus, staphylococcus and different 

diplococci) ; L, leucocytes. 

fusiform, bent, or having large nuclei, arising from regions 
where the epithelium proliferates abundantly. 

3. Cylindrical cells, arising either from the healthy por- 
tions of the canal or, when they are in superimposed layers, 
from the prostatic glands. 

4. Hyaline cells, to which Ftirbringer has given the 
name iodophilic cells, because of the ease with which they 
are colored by iodin reagents ; they are also met with in 
the normal urethra. 

5. Cells which have undergone fatty degeneration. 
These last are quite rare. 



52 CHRONIC URETHRITIS 

c. Leucocytes give to the discharge its purulent aspect ; 
they are polynuclear and, aside from this, have no special 
characteristic. 

d. Micro-organisms may be entirely absent in certain 
shreds or threads which are, in this case, aseptic. Generally 
the urethra is inhabited by a rather rich microbic flora, of 
which various specimens are found in the discharge — micro- 
cocci and bacteria of every description. These microbes 
have, as far as we know up to the present time, no impor- 
tance. As to the gonococcus which gives to the disease its 
special feature, we do not invariably find it. It even hap- 
pens that it escapes repeated and minute examination, and 
that, a relapse coming on after one or another cause, it ap- 
pears in large numbers. It is therefore necessary not to at- 
tach to the search for it in a given case the decisive import- 
ance which is frequently attributed to it ; we can never 
conclude that the disease has lost its contagious nature, even 
after we have failed to find gonococci present in repeated 
and carefully made examinations. (See Chapter XV.) 

Besides these morphological elements, which are habit- 
ually present, we may also find others which depend upon 
a complication of the disease. Such are the red globules 
encountered especially when an acute recurrence of a pos- 
terior urethritis takes place, spermatozoa, and debris of 
various kinds. 

III. Localization. — The microscopic examination of 
the products of suppuration gives no information as to the 
portion of the canal in which the process has taken place. 
We cannot distinguish pus formed in the posterior urethra 
from that which forms in the anterior part of the canal. 

This distinction would, however, be of importance, be- 
cause posterior urethritis demands quite a different treat- 
ment from that of the anterior portion. 

In face of this insufficiency of direct examination, we 
should resort to indirect methods, which we shall describe 
and which are based upon the same principle. 



SUPPURATION 53 

The urethra, from a physiological as well as from an 
anatomical point of view, is divided into two quite distinct 
segments separated from each other by the external sphinc- 
ter muscle. The tonic contraction of this sphincter is very 
euergetic and generally closes the urethra in an almost 
hermetical manner. It results from this that all liquids 
introduced into the canal this side the sphincter are at once 
projected toward the meatus by the elastic pressure of the 
walls. On the contrary, liquids introduced beyond it flow 
toward the bladder and become mixed with the urine. This 
rule, exact from a physiologic view, is perhaps not abso- 
lute; we see quite frequently, in spite of the action of the 
sphincter, that pathological fluids pass from the posterior 
region to the anterior region and show themselves at the 
meatus. 

Hence the procedures based upon the sphincter action 
have only an approximate value. We shall describe them 
presently. 

a. Two -glass test (Thompson). The patient retains his 
urine long enough to accumulate in the urethra all the 
secretion possible. At the moment of urination he passes 
the fluid into two glasses. The pus which may have been 
in the urethra will be washed out by the first flow of 
urine, and will be found exclusively in the first glass. 
The urine contained in the second will be absolutely clear, 
but, as the pus formed in the posterior urethra flows into 
the bladder and there mixes with the urine, if a posterior 
urethritis exists, the contents of the second glass will be 
turbid. 

1). Three- glass test (Jadassohn). The patient urinates 
successively into three glasses. The first contains the pus 
still adherent to the walls of the canal; the second glass, 
in case of posterior urethritis or of cystitis, will contain 
the secretions which have flowed toward the bladder and 
mixed with the urine ; finally the muscular contractions 
which mark the end of micturition press out the contents 



54 CHRONIC URETHRITIS 

of the posterior urethra, and cause to escape, especially 
from the prostate, all the pus which may have accumula- 
ted here; this pus will be found in the third glass. 
From this there are three possibilities: 

1. If the first glass alone holds purulent urine, ante- 
rior urethritis. 

2. If the second and third glasses also show it, urethro- 
cystitis or cystitis. 

3. If the second glass contains pus, but the third glass 
holds still more, posterior urethritis and x>rostatitis . 

But the first glass may also contain threads coming 
from the posterior urethra. If we wish to eliminate them, 
we begin by removing them by means of lavage. In this 
manner the pus which the first glass might contain would 
certainly have its origin in the posterior urethra, and this 
diagnosis would be correct even if the urine collected in 
the second glass was perfectly clear. The secretion of 
the posterior urethra may indeed be too scant to penetrate 
into the bladder. Washing out the anterior urethra is 
best made in the following manner: 

A Nelaton catheter is introduced up to the level of the 
sphincter and, by means of it, a certain quantity of water 
is injected to the bottom of the anterior urethra. The 
canal being closed at this point, the fluid necessarily flows 
back toward the meatus and brings with it all the secre- 
tions adhering to the mucous membrane. If we make this 
lavage under a proper pressure, we obtain good results; if 
the pressure is too strong, the resistance of the sphincter 
may be overcome, and the injected fluid penetrates into 
the bladder, carrying with it the threads which will after- 
ward be found in the urine, and whose presence will lead 
to a faulty diagnosis. With the view of surely avoiding 
this inconvenience, we use for washing a solution of iodid 
of potassium, 1 to 1000. After having collected the urine, 
we add a few drops of perchlorid of iron. In case the 
washing fluid has passed into the bladder, the urine takes 



SUPPURATION 55 

on a characteristic bluish color. If it has not passed into 
the bladder, the urine remains uncolored. 

IV. Kollman's Procedure. — Kollman employs five 
glasses in his test, which is, by preference, made in the 
morning before the first urination has occurred. The pa- 
tient, while standing, has a soft catheter introduced up to 
the bulb, and lavage is made by means of a syringe. The 
pressure should be slight for fear of forcing the liquid into 
the posterior urethra, which, according to Kollman, is 
easily done. 

The washing water is collected into a first glass, into 
which is poured successively all the water which flows from 
the canal at each washing as long as it brings with it any 
threads. Once the washing water returns clear this last 
specimen is preserved in a second glass. Now the patient 
urinates into three glasses, just as in Jadassohn's test. 

Such are the various processes usually employed in 
clinical work to disclose the existence of posterior ure- 
thritis. They are all based on the role played by the 
membranous sphincter (compressor urethras) ; but the 
tonic contraction of this muscle, be it ever so energetic, 
forms no absolute obstacle to the passage of small quan- 
tities of fluid . This is especially true when the membrane 
is diseased, and we have constant examples of the facility 
with which liquids can at times traverse the membranous 
portion, instead of flowing through their habitual chan- 
nels. Therefore we cannot attribute an absolute value to 
the results of urine examination. We may, however, avail 
ourselves of them in practice, especially when to the 
results obtained are added those furnished by the other 
explanatory processes which follow. 

[As regards these three tests, they are based on the de- 
velopmental history of the uro-genital organs, which differ- 
entiates the posterior from the anterior urethra. The real 
closure of the bladder is effected by the compressor urethras 
muscle according to this view and not by the sphincter 



56 CHRONIC URETHRITIS 

vesicae. The compressor urethrae is thought to be in a 
state of permanent contraction, and when the bladder is dis- 
tended the sphincter vesicae gives way and forms, tem- 
porarily, a part of the bladder. Thus the so-called neck 
of the bladder is formed. An analogous condition exists 
when the os internum of the pregnant womb is obliterated 
at the end of gestation. Here, too, the internal os and the 
whole cervix cease to exist when parturition takes place. 
When a catheter is introduced beyond the compressor ure- 
thras muscle, the fluid injected through it will enter the 
bladder and will not escape through the meatus in front. 
Consequently the secretions which form in the posterior 
urethra will flow backward into the bladder, and those 
formed in anterior portion in front of the compressor will 
flow toward the meatus. 

Contrary to this view, Zeissl holds quite a different 
opinion. He emphasizes the fact that, in exercising a pres- 
sure on the prostate and seminal vesicles, we find the se- 
cretions appearing at the meatus. This could not happen 
if the compressor urethrae would really form an unyielding 
barrier between the posterior and anterior urethra. He 
supports his contention by recent investigations made by 
Rehfisch, Frankl-Hochwart, and Zuckerkandel, which point 
toward the sphincter vesicae as forming the real closure of 
the bladder. We are not prepared to go into the merits of 
these different views. There are certainly many points for 
and against each, and the authors of this volume have 
therefore cautiously avoided attributing too much impor- 
tance to the urinary examination alone. But the two-, 
three-, and five -glass tests serve a very useful purpose, giv- 
ing a working formula, as it were, and greatly elucidate 
matters in complicated cases. As to Thompson's two-glass 
test, its value could be improved if the Goldenberg-Jadas- 
sohn modification be more frequently used. It consists of 
washing out the anterior urethra by means of a short glass 
or hard rubber tube connected with an irrigating apparatus 



SUPPURATION 



57 



previous to urination, — the height of the irrigator being 
one and one-half meters, and the meatus not closed entirely 
by the tube, which is introduced a little beyond the fossa 
naviculars. Flushing carried out in this way will not 
permit fluid to enter the posterior urethra, as was con- 
clusively shown by the prussian blue test employed by 
Goldenberg after Lohn stein's advice.* In Lohnstein's ex- 
periments made for the same purpose, the fluid entered the 
posterior urethra thirty- seven times out of ninety-four 
cases. The discrepancy explains itself by the fact that 




Fig. 5. Janet-Frank Syringe 

Can be taken apart and sterilized by boiling. Crystal barrel and 

nickeled metal casing. 

Lohn stein made his irrigations by means of a Nelaton cath- 
eter. Goldenberg points out that the mucous membrane 
contracts about the eye of the instrument, causes the liquid 
to form a whirl directed towards the bladder, its reflux is 
obstructed, in consequence of which the compressor muscle 
relaxes. 

We are in the habit of using for this purpose a hand- 
syringe of a capacity of three to five ounces, and an olive - 
shaped soft rubber tip (Fig. 5) . The pressure can be regu- 
lated with more precision by this instrument than with any 

*A one-half per cent solution of ferrocyanide of potassium was used for irrigation. 
If only a few drops of this solution enter the posterior urethra, the first portion of the 
urine, at least, will give the prussian blue reaction on adding tinct. ferri chloridi. 



58 CHRONIC URETHRITIS 

other. The minutest resistance offered to the ingress of 
the fluid is distinctly felt in the thumb which governs the 
forward motion of the piston. We use this instrument by 
preference for all diagnostic and therapeutic purposes 
where urethral washings are necessary. We can. conscien- 
tiously recommend it as the safest contrivance of its sort, 
having no less a sponsor for it than Guyon, who calls it an 
"instrument de precision." The fluid used for flushing 
the anterior urethra is a warm four per cent solution 
of boric acid. It is preferable to use filtered or dis- 
tilled water in order to more easily recognize the washed- 
out threads iu the modified Thompson as well as in the 
original Jadassohn tests. We flush the anterior urethra 
until the wash-water returns perfectly clear without any 
threads. The patient is then directed to void his urine into 
two beakers for Thompson's test, into three beakers for 
Jadassohn's test, or into five beakers when Kollman's test is 
to be-used. In employing these flushings without a catheter 
and with the use of the hand-syringe and olive-shaped tip, 
we possess in these modifications an almost faultless means 
of demonstrating the presence of a posterior urethritis. 
Of these three tests just named, the latter two will bring 
forth in their last portions the contents of the prostate 
or seminal vesicles with reasonable security. The contrac- 
tion of the bladder at the end of the act of micturition is 
followed by the continued wave -like contraction of the cir- 
cular muscle-fibers enveloping the prostate. This latter 
mechanism, which works almost synchronously with the 
sphincter of the bladder, will exert compression on the 
prostatic glands and express the contents of their ducts. 
These clonic contractions are even capable of emptying 
clogged glandular ducts and pent-up gonococci, which will 
then appear in the last portion, i. e., in the second, third, 
or fifth glass of the tests.] 



CHAPTER VI 

DISTURBANCES OF SENSATION 

The functional troubles and the painful symptoms of 
which the patient complains vary extremely in intensity. 
They depend not only upon the nature and gravity of the 
lesions, but also upon the particular nervous sensibility of 
the patient. At one time the}" are in direct association 
with the diseased areas ; they consist, for example, of a 
slight tickling or a weak sensation of burning which is 
produced during the act of micturition, when the affection 
is located in the anterior urethra. When the posterior 
urethra is involved, the patient complains of a slight heat, 
a burning, showing itself especially at the end of urination, 
and irradiating at times the whole length of the penis ; 
or still again the patient feels a sensation as of a sting at 
the moment of ejaculation. In the latter case it seems, at 
times, that changes have occurred in the ejaculatory ducts. 
When a stricture exists, or even simply a loss of elasticity 
in the walls of the canal, the patients often complain of a 
difficulty in urination ; at other times, on the contrary, 
they are tormented by frequent calls to urinate, and they 
experience a peculiar sensation of incomplete and insuffi- 
cient miction which is not accompanied by any re- 
tention of urine, however slight. This point is easily 
verified by means of the catheter. These abnormal 
sensations and functional disturbances disappear in gen- 
eral under the influence of a properly directed therapy, as 
they are solely connected with the lesions in the canal. 
They are most marked after excesses and fatigues of every 
kind. 

(59) 



60 CHRONIC URETHRITIS 

Furthermore, when the patient presents a more or less 
marked nervous hyperexcitability, these local sensations 
become accentuated, not alone to the extent of preying 
upon his mind already preoccupied, but they extend, at 
times, with considerable force and intensity into the most 
varied nerve -territories, and often to those most remote 
from the seat of the disease. In this case they constitute 
what is called sexual neurasthenia. 

Sexual neurasthenia may develop upon a ground pre- 
pared by heredity, or even in a subject of habitually 
normal nervous system, under the influence of general 
causes which engender all the varieties of neusrathenia. 

It is quite generally believed that sexual neurasthenia 
is occasioned only by lesions of the posterior urethra and 
particularly by those of the prostate. These organs are, 
indeed, the seat of an exquisite nervous sensibility, which 
regulates the different physiological acts of micturition and 
of coitus. But this sensibility is not caused by those le- 
sions alone which are located in the posterior urethra or in 
the prostate. Although it may be physiologically called into 
play by excitations originating in the canal of the anterior 
urethra, or even outside of the latter in the region of the 
prepuce or glans penis, for example, it can also be caused 
in a pathological manner by remote lesions. This is par- 
ticularly true in subjects of neuropathic taint. In the 
latter an excitation starting from the glans penis, or from 
the anterior urethra, will set up an intense desire to uri- 
nate. A phimosis or a chronic anterior urethritis will 
give rise in the same way to sensations whose apparent 
seat is in the posterior urethra, without the latter being 
anatomically injured. These sensations may disappear if 
we act upon the nervous hyperexcitability by means of an 
appropriate treatment (hydrotherapy, sedatives, etc.), 
but they reappear almost without fail later on; while a 
well-directed local treatment will cause a lasting disap- 
pearance. The urethroscope frequently confirms this fact, 



DISTURBANCES OF SENSATION 61 

and we can, in this manner, show that in those subjects 
affected with severe nervous disturbances, the posterior 
urethra and its annexes are either but slightly or not at 
all affected, while the anterior urethra presents manifest 
lesions. The cure of the latter assures at the same time 
the complete relief of the patient. 

We must further add that if chronic anterior urethritis 
can of itself give rise to sexual neurasthenia, the same 
is true of posterior urethritis, while according to our opin- 
ion, the last -mentioned ease is much less frequent. We 
may further state that the division of anterior and pos- 
terior urethritis, very useful from a didactic standpoint, 
does not clearly correspond with what is actually observed 
in practice and that the two forms often coexist; the deepest 
lesions are generally encountered in the anterior urethra. 

However the case maybe, the symptoms complained of 
by the patient maybe referred to various regions, and pre- 
sent at times an extremely difficult problem. These may 
consist in sensations of heat, burning, tickling, pricking, 
dull pains in the region of the urethra, or of constriction 
of the glans penis; they may appear in the form of crises 
which come on either before or during urination. The 
latter is at times modified by irregular spasmodic contrac- 
tions of the sphincter or of the vesical muscles. The 
patient is now conscious of an inexplicable retention, or 
he experiences a frequent and unjustifiable desire to urinate. 
The frequent micturitions do not occur during the sleeping 
hours, which stamps them with a particular character. 

As to coitus, the habitual sensations may equally be- 
come modified; at times they are diminished and even 
disappear entirely; at other times, on the contrary, they 
become exaggerated or altered in character, and even dis- 
tinctly painful. Nocturnal emissions may occur, or the 
phenomena of premature ejaculation may constitute an 
irritable weakness (reizbare Schwache). Again, erections 
may become difficult or incomplete, the ejaculation is 



62 CHRONIC URETHRITIS 

retarded or does not even occur at all; thus bordering upon 
more or less complete impotence. Finally, we encounter in 
some patients spermatorrhea or prostatorrhea often at the 
time of micturition or more commonly at the time of defe- 
cation. 

Furthermore, the abnormal sensations which we have 
described may spread to the neighboring parts, irradiate 
along the cord, show themselves in the testicles, in the 
perineum, in the inguinal region, or surrounding the anus. 
Aside from the symptoms which more or less directly call 
his attention to the origin of the affection, the patient suf- 
fering more or less from sexual neurasthenia may present 
the symptoms common to general neurasthenia; these we 
will not here describe, but we will add that at times these 
unfortunates reach a state of physical and moral depression 
which leads them to suicide. 



CHAPTER VII 

EXAMINATION OF TEE PATIENT 

The physician called to examine a patient affected with 
chronic urethritis, should determine with exactitude and pre- 
cision the nature and seat of the lesions which the subject 
presents. Indeed a vague diagnosis will not permit us to lay 
out an efficacious plan of treatment. To reach this indispens- 
able precision, we must emploj^ modes of exploration which 
are sufficiently delicate. Those generally employed are: 

I. Direct Examination.— Direct examination by means 
of sight or touch may furnish some indications; we see, for 
example, if there is any discharge or if the meatus is red or 
inflamed. We may examine by palpatation to discover if 
there exist along the urethra foci of inflammation which 
may be recognized by special induration. Foci developed 
around Littre's glands and their excretory ducts may be 
made out in the form of small hard pearls, having 
generally the dimensions of a pin's head. At other times 
the whole wall of the canal is indurated over a more or less 
considerable extent, and gives the sensation of a tube with 
resistant walls. Palpation is best carried out when the 
walls of the canal are distended by a catheter or dilator; we 
succeed in this manner, at least in the perineal region, in 
discovering very clearly the different foci of infiltration, 
especially when they reach a certain depth in the urethral 
mucous membrane. These procedures of direct examina- 
tion by inspection and palpation are naturally insufficient 
for the examination of lesions situated in the deep urethra. 
We must here have recourse to exploration by means of 
instruments. 

(63) 



64 CHRONIC URETHRITIS 

II. Sounds and Urethrometers. — The lesions of 
chronic urethritis, as soon as they have acquired a certain 
importance, have the result of modifying the elasticity of 
the walls of the canal, and generally also the caliber of the 
latter. If the canal were perfectly cylindrical, we could, in 
introducing a sound of proper size, perceive a resistance at 
the diseased points, and thus note their location; but the 
canal enlarging, on the contrary, as we penetrate more 
deeply, the slight modifications in the caliber of the deeper 
parts do not arrest a sound whose dimensions have been 
calculated from the size of the meatus. It is thus that 
exploration by means of ordinary bougies does not per- 
mit of diagnosticating strictures other than the rather 
tight ones. 

There exist still other causes of error, making this kind 
of exploration altogether insufficient r in the majority of 
instances. Bougies a ooule (Fig. 6), give more precise 




Fig. 6. Bougie a boule. 

indications. These are small, elastic, thin, and flexible 
bougies, ending at one extremity in an olive -shaped 
expansion of definite diameter. It is necessary to have a 
whole series of such bulbs corresponding to the different 
numbers of the Charriere scale. To use them it is neces- 
sary to pick out one corresponding to the caliber of the 
meatus, that is to say, one whose bulb penetrates into the 
urethra in making but very slight pressure. Once the bulb 
is introduced, it is carried slowly in, so as to cause it to 
glide the whole length of the canal as far as the bulb. 
This should be done so that not the slightest resistance is 



EXAMINATION OF THE PATIENT 65 

felt either in entering or being withdrawn. As soon as 
there is, at a given point, a slight modification of the 
caliber, this narrowing, even when not pronounced, is 
indicated by a sensation of a projection, or ledge, which 
is especially noticeable when the bnlb is withdrawn. If a 
stricture of smaller diameter than that of the meatus 
exists, the bulb will not pass, and we must select bougies 
with numbers running smaller and smaller, until we reach 
one which will pass through the stricture, and thus give 
the measure of its caliber. When we have reached the 
membranous portion, the bulb is always arrested by the 
contraction of the sphincter of the urethra (external 
sphincter). The patient experiences, at the same time, a 
more or less violent, painful sensation, followed by a desire 
to urinate when, the sphincter being passed, the bulb 
traverses the membranous and prostatic regions. 

This process of exploration described by Guyon and 
employed by him, so to speak, to the exclusion of all other 
methods, is quite a sensitive test. It permits the discovery 
of even slightly marked strictures, and enables us to 
measure their calibre and even their length. If we pre- 
sume or suspect that a posterior urethritis exists, Guyon 
advises that a series of to-and-fro motions be carried out 
in the deeper parts ; a sort of sweeping about the canal so 
as to collect upon the shoulder of the bulb the pus which 
may be encountered, and bring it to light. But this 
method, besides being rather painful, is quite untrust- 
worthy. 

Furthermore, the procedure is insufficient if the lesions 
are too diminutive to oppose an obstacle to the passage of 
the bulb, to indicate their presence by the characteristic 
sensation on entering and withdrawing the instrument. 

Urethrometers are still more sensitive than bougies a 
boule. The urethrometer most employed is that of Otis 
(Fig. 7). It is composed of a thin steel stem whose 
visceral extremity is constructed in such a way as to be 



66 



CHRONIC URETHRITIS 




dilated in the form of a spindle by means of a thumb- 
screw placed at the opposite extremity of the instrument. 
The movements of this screw bring into 
play at the same time a movable hand set 
upon a dial -plate marked in degrees cor- 
responding with the numbers of the Charriere 
scale. The dilatable spindle is covered with 
a rubber cap which can be readily removed 
and cleansed ; this is intended to prevent 
pinching of the tissues by the steel joints of 
the instrument. 

By means of this apparatus we can take 
a very exact measure of the urethra's caliber 
at its various points, and thus find those in 
which a chronic infiltration has diminished 
the elasticity of the mucous membrane. 

All the instruments, as well as the methods 
of examination which we have described, 
have for their aim the discovery of the exact 
location of the lesions whose existence has 
been determined. 

Unfortunately, the results obtained in 
this way are insufficient in many instances, 
and lack precision. ' There exist, iudeed, a 
certain number of urethral lesions of very 
small dimensions which are, however, the 
origin of serious disturbances. These may 
be small glands which are inflamed and sup- 
purate, or destroyed cysts in the mucous tis- 
sues. Now these lesions, in spite of their 
restricted dimensions, may produce a long- 
lasting discharge ; they may, on the other 
hand, not manifest their presence by any 
ub^thkom™. symptom over a long period of time. No 
a. spindle opened, discharge is seen, no threads float in the 
a luifer cip sed " urine, but, nevertheless, the patient is affected 




EXAMINATION OF THE PATIENT 67 

with an acute exacerbation without being' exposed to any 
source of contagion. Such instances are frequently en- 
countered and seem inexplicable, and it is thus that chronic 
urethritis seems at times to assume a mysterious character. 
The treatment is then directed against an imperceptible 
enemy who shields himself from view, and whose offensive 
reappearances upset all our therapy. 

It is in such instances that the utility of a more precise 
and more delicate means of investigation are apparent. 
In every case, however, we must know in the most exact 
way the nature of the lesions; it is indispensable, there- 
fore, to possess a method which permits us to constantly 
follow the phases of the disease and the progress of the 
cure. 

Endoscopy gives [us this means. We will, therefore, 
devote a special chapter to its study. 



CHAPTER VIII 

URETHRAL ENDOSCOPY {URETHROSCOPY) 

I. Instruments and Operative Technique.— Before 
describing the instruments which have been brought to the 
present state of perfection, it will be of interest to cast a 
glance over the past. The history of urethral endoscopy 
is quite a long one. Since the time (1853), when Desor- 
meaux described the instrument which bears his name, 
and even before his time, many authors had applied their 
ingenuity to the construction of devices which would 
permit the illumination of the canal. But all these 
urethroscopes had one fault in common. It was neces- 
sary, in order to obtain the desired light, to fasten a 
lamp upon the instrument, which made its manipulation 
difficult and uncertain. 

Grilnfeld recognized this defect and made an indepen- 
dent source of illumination in employing a fixed light; he 
used, in succession, an oil lamp, a gas lamp and, finally, 
an electric lamp. From these he reflected the rays by 
means of a head mirror into the axis of the endoscopic tube. 
This simple modification in facilitating the manipulation of 
the instrument, caused urethroscopy to really enter upon a 
practical field, and it is from this epoch that the first 
technical treatises date. Griinf eld's method was, in turn, 
elaborated by various authors, and there appeared succes- 
sively the Aerouretliroscope of Antal, the Diaphanoscopes 
of Schiitze and of Casper, the Panelectro scope of Letter, 
Otis 7 instrument, etc. Finally Oberlander, in his turn, 
made a complete modification of the instrument. Fol- 
lowing successive improvements which he made, he 

(68) 



URETHRAL ENDOSCOPY 69 

finally succeeded in constructing a perfect apparatus, and 
thus made an absolutely complete study of this important 
portion of urology. 

Oberlander recognized the fact at the outstart that the 
urethroscope tubes, which had been employed up to his 
time were of much too small a caliber. He showed that it 
was almost always possible to use tubes of a greater diam- 
eter, a fact which increased the surface to be examined 
and, consequently, made the examination much more 
complete. 

Finally, following the example of Nitze, to whom 
belongs the original idea of this innovation, he introduced 
an electric source of light in the extremity of the tube, 
quite close to the region to be examined. He thus ob- 
tained a light much superior to all others and succeeded 
in studying the most minute anatomical details of the 
region . 

[Undoubtedly the Nitze- Oberlander urethroscope created 
modern urethroscopy. Although previous observers have 
worked out detailed accounts of lesions, their diligent 
researches were necessarily limited. Oberlander was en- 
abled, by the use of his instrument, to perceive details 
hitherto unseen, and to build up a system on an anatomo- 
pathological basis. To him is due the credit of elevating 
urethroscopy to the rank it merits as a legitimate, indis- 
pensable procedure for diagnosing and treating chronic, 
circumscribed lesions of the urethra. Kallmann's urethro- 
scope studies have won for this method scores of friends, 
and it is largely due to his untiring efforts that chronic 
gonorrheal urethritis in all its protean aspects is under- 
stood and cured. Urethroscopy gave him the impulse to 
invent his ingenious instruments for which the profession 
is so largely indebted to him. 

The only drawback of the well-nigh perfect urethro- 
scope of Nitze -Oberlander was the unprotected incandes- 
cent loop of platina which necessitated a cooling device. 



70 CHRONIC URETHRITIS 

This, of course, made the instrument somewhat cumber- 
some and expensive. Besides, when mopping the urethra 
with the cotton -carrier, the light had to be extinguished to 
prevent the cotton catching fire. The observer was apt 
to lose, by this maneuver, the particular point of the urethra 
he had in view previously. But these shortcomings did 
not detract much from the value of the instrument with 
those accustomed to work with it. The idea to introduce 
small incandescent lamps into the urethroscopic tube without 
cooling device was tried by Heynemann of Leipsic, accord- 
ing to a written statement from him. He states therein 
that Br. Loewenhardt of Breslau had, a few years ago, 
invented such an instrument especially for the illumina- 
tion of the posterior urethra. But it proved to be of no 
success, owing to the at that time unknown technique to 
produce mignon lamps. It was reserved for American 
ingenuity to perfect mignon lamps of such low tension, 
as to create a minimum of heat. Dr. Henry Koch of 
Rochester has caused such mignon incandescent lamps to 
be made, and such a urethroscope without water- cooling 
apparatus provided with a megaloscope was demonstrated 
by Dr. F. C. Valentine in 1899. Since then many improve- 
ments and modifications have. been added, some of which 
we helped to devise. The fact is, that we now possess an 
urethroscope into which a mignon lamp is introduced 
instead of an unprotected platina loop, the source of 
illumination being derived from dry cells. 

The lamp consumes an energy of 3% volts and 0.2 of an 
ampere. Therefore the energy consumed is less than 1 watt. 
The heat so generated is too low to be perceived, and isdis- 
pated by the adjoining metallic parts which consist of the 
socket for the lamp and the metal light -carrier. In a sense 
even the urethroscopic tube serves the purpose of dissipa- 
tion. It takes ten minutes before the tube becomes per- 
ceptibly warm, and after fifteen minutes patients have 
not complained of an unpleasant sensation of heat. As 



URETHRAL ENDOSCOPY 



71 



• f„„c are rarely conducted for such 
nrethroscopie exammatrons a« rar y ^ ^ q£ 

a leugth of tune i - «* « ^ consider ution. 

"ISSylTfSlh the light. A rene « , whrch » 
proSS needed ever, six — cos^g* ^ 

rheostat govern. ; the cnrre* and the J*^, p&l , of 

We have devised a small wneei u 




l BETHKOSOOPE. 



Fig. 8. CHETrwooi 

i rn\> \< Pasilv governed by the right 
the Ught-carner wto^ea** g ^ ^.^ 

thumb holding it. Likewise nave w ht . carrier on 

is added The whole apparatus, known as Chettwooa 
Lthrotcope, hut slightly modified in form (Fxg. 8) 



IS 



72 CHRONIC URETHRITIS 

compactly put up in a handsome wooden box and can be 
carried about easily as an ever -ready and simplified ap- 
pliance, which will gain to urethroscopy, it is hoped, num- 
bers of devotees. 

As to the question how to learn to practice urethro- 
scopy, the answer is that it must be acquired through one 
already well versed in this particular kind of observation. 
The rudiments can very easily be grasped, but the explana- 
tion of what we see and the construction of the picture 
can only be attained by personal teaching. It is, however, 
by no means an impossible feat and need not deter any 
one from practicing it. The student who begins to use 
the ophtalmoscope is bewildered first, but soon learns to 
distinguish details. It is the same with the urethroscope. 

Concerning the position of the patient, we prefer the 
semirecumbent one. In this half- sitting attitude the 
different parts of the urethra can be discerned with more 
ease for the operator and with less unpleasantness for the 
patient. The pendulous and bulbous urethra, even the 
pars membra nacea, can thus be examined comfortably. 
Grunfeld himself prefers the patient in this position, so 
does Kollmann. Besides, it is worthy of some considera- 
tion that the patient should witness the procedure and feel 
safer in his expectations. The physician will have to 
content himself by conducting the examination standing. 

One incident experienced by us and, as far as we know, 
not yet recorded, maj r be mentioned here. When sopping 
up the liquids, should the moist cotton-carrier, in its with- 
drawal, come in contact with the lamp, a fine vapor is 
generated, which forms a haze -like fog, through which the 
divergent rays of the electric light can be seen to irradiate, 
much like the rays of the lighted street-lamps when they 
pierce the fog. This phenomenon is perplexing for a short 
while, but is soon dissipated by the haze escaping through 
the tube. As cotton -carriers we prefer, instead of the 
handy but breakable long match -sticks, wire tampon car- 



URETHRAL ENDOSCOPY 73 

riers serrated at the visceral end and bent in a right angle 
at the handle, thus permitting* an unobstructed view.] 

Description of the Apparatus. — The endoscopic tubes 
employed by Oberlander are, as we have stated, of a 
larger diameter than those formerly in use. They cor- 
respond to numbers 23, 25, 27, 29, and 31 of the Char- 
riere scale. Measurements made by Oberlander and Kall- 
mann on three hundred patients, resulted in finding that 
two or three per cent only of the subjects presenting 
themselves for examination had a meatus too tight to 
admit a number 23, while in sixty to seventy per cent, 
number 27 could be readily used, and even number 29. 
In ten per cent it was necessary to use a number 23, and in 
twenty-five per cent a number 25. Only one of the patients 




Fig. 9. Oberlaenper's Urethroscope Tube. 

had a meatus large enough to admit a number 31. Our 
personal observations are in accord with these figures. 

Numbers 27 and 29 are those by far most frequently 
employed, and there is a decided advantage in making use 
of the largest tube possible. The surface to be examined 
becomes stretched to its greatest capacity, and the folds of 
the mucous membrane are effaced in such a way that small 
lesions which they might cover and hide are brought to 
light. 

Urethroscopes (Fig. 9) are constructed of silver, with 
very thin Avails. They are furnished with an obturator 
of conical extremity, which serves to facilitate their intro- 
duction into the urethra. This is to be gently withdrawn 
when the tube is in place. 

For this reason the obturator is hollowed out with a 
lateral groove to allow the air to pass and prevent its 



74 CHRONIC URETHRITIS 

acting as a piston during withdrawal, and thus to forc- 
ibly draw the mucous membrane into the distal end of 
the tube. There are to be had obturators with a hinge 
(Fig. 10), giving to the urethroscope the form of a jointed 
or elbowed sound, which facilitates introduction into the 
posterior urethra; it is possible, then, by turning a screw 




Fig. 10. Obkrmendkk's Jointed Urethroscope. 

to straighten the obturator and withdraw it from the tube 
when the latter is well in place. But this ingenious in- 
strument is but rarely employed, because it is generally 
an easy matter to introduce a straight tube into the pos- 
terior urethra. 

The ocular extremity of the tube bears a small projec- 
tion, on which the light -carrier is fastened, as we shall 
presently see. The opposite extremity of the latter is 
slightly beveled, like the mouth -piece of a flute, and it is 
upon the prominent portion of this beak that the incandes- 
cent thread rests, so as to light up freely the surface of 
the mucous membrane. 

Finally, Oberlander employes a dilating tube composed 
of two concave pieces put together in the form of a cylin- 
der, when not in use, and which can be separated at will 
like the valves of a Cusco speculum, once the urethroscope 
is introduced to the point which is to be examined. It 
is possible, in this way, even when the meatus is very 
narrow, to stretch the mucous membrane out completely 
at the widest portions of the canal and study its minutest 
details. Before the instrument is withdrawn it should 
be closed. Since the margins of the two semi -cylinders 
do not fit exactly upon each other, no risk is run in pinch- 
ing the membrane in closing the tube. This apparatus 



URETHRAL ENDOSCOPY 



75 



does very well for a detailed study of the lesions of the 
mucous membrane; but in general practice the simple 
straight tubes are more convenient and are amply suffi- 
cient. To light up the surface of the canal, Oberlander 
employs the light from a thin thread of platinum heated 
to a white heat by the passage of an electric current. 
This thread rests upon a small hollow plane in which a 
stream of cold water constantly circulates, which is furnished 
by an irrigator placed at a convenient height. The illu- 
minating apparatus is placed at the extremity of a rod 
or light -carrier, in such a manner that the thread of 
platinum comes quite close to the extremity of the endo- 
scopic tube without, however, being able to reach the 
mucous membrane. Finally the extremity of the light - 
carrier is beveled so that the thread is not visible and 
the eye of the observer, not being inconvenienced by the 
glare of direct light, distinctly sees the endoscopic image. 
The light -carrier, as a whole, occupies so little space 




Fig. 11. Oberlaender"s Light-carrier with Cooling 
Attachment and Tube. 



that, when it is well applied to the wall of the instrument 
its presence is scarcely noticed. All of these details will be 
better understood by referring to Fig. 11. 

[The insertion of the incandescent curved platinum 
thread into the light-carrier was a source of annoyance 
when an exchange was necessary. To avoid this, Kollmann 
has devised a modified fixation of the light, and Wossidlo 
a new adjustment of the platinum wire.] 



76 CHRONIC URETHRITIS 

Besides the endoscopic tubes and the light- carrier cer- 
tain other accessory instruments are employed, such as 
cotton -carriers, thin rods on whose extremity a small 
wad of cotton is twisted. These are passed down the endo- 
scopic tube to soak up any fluid to be found upon the 




GEO. TICMANN & CO 



Fig. 12. 

KOLLMANN'S INTRA-URETHRAL SPATULA. 



mucous membrane of the urethra. Oberlander, Kollmann, 
and others have had constructed: 

1. Small stylets, curettes, spatula (Fig. 12), capillary 
probes (Fig. 13) and aspirators (Fig. 14) to be introduced 
into the glands of Littre and to extract their contents. 

2. Knives to make pricks or incisions into large foci of 
infiltration (Fig. 15). 

3. Sounds insulated nearly to their extremity, which are 
intended to be introduced into glands which it is desired to 
destroy by electrolysis (Fig. 16). 



G.TIEMANN&CO. 



Fig. 13. 
kollmaxns intra-urethral probe. 




4. Instruments intended for intra -urethral galvanization 
(Fig. 17), and for injection into glands (Figs. 18 and 19). 

These instruments may be employed, but are by no 
means indispensable and, indeed, they are but rarely used. 

Finally, the necessary electric current may be furnished 



G.TItMANN & CO. 



Fig 14. Kallmann's Capillary Aspirator. 
For removing discharges from the urethral glands. 




CEO T1EWANN & CO. 



Fig. 15. Kollmann's Intra-Crethral Knife 





GeoTlEMANN *t» 

Fig. 16. 

Kollmann's Electrolytic Pointed Probe. 

For the destruction of urethral glands. 




G.TiEMANN&CO. 



Fig. 17. 
Kollmann's Intra-Crethral Electrode. 



Oeo. TiEV.ANN 8- Co 




Figs. 18 and 19. Kollmann's Cannula and Syringe.' 
For injections into the urethral glands. 




Fig. 20. Kallmann's Complete Apparatus. 
For electro-uroscopy, cystoscopy, electrolysis and galvanization. 



URETHRAL ENDOSCOPY 



79 



by accumulator}' or by bichromate of potassium batteries; 
a convenient rheostat permits the current to be regulated 
at will. 

[Figure 20 shows a complete electro-urethroscopic outfit 
containing appliances for urethro- and cystoscopy, electro- 
lysis, and galvanization. The instruments are furnished 
by Hej'nemann, instrument maker in Leipsic] 

[Fig. 21 represents Otis' improved urethroscope. Here 
the light is projected into the tubus by means of an electric 
lamp condensed by a lens, and a funnel-shaped diaphragm 




Fig. 21. Improved Otis Urethroscope. 



to cut of extraneous light. This whole light -source is 
properly adjusted to the tube by an immovable arm, which 
secures a proper centering of the light rays at the other 
extremity of the tube. 

This ingenious instrument is no doubt the best of ure- 
throscopes having the light outside the tube, and is worthy 
of a place in one's instrumentarium. We prefer the direct 
light introduced into the tubus.] 

Operative Technique.— This is how we proceed to make 
a urethroscopic examination: First of all, we must be 
sure the instrument works well. The platinum wire is 



80 CHRONIC URETHRITIS 

fastened at the extremity of the light- carrier in such a way 
as to be removed and replaced readily. We must, there- 
fore, examine to see if it is fixed in place. The stop -cock 
which regulates the current of water is opened, and we 
make sure that the flow is established. The electric current 
is now turned on, and the rheostat is manipulated until a 
suitable light is secured. Being thus assured that all is 
in working order, the current is interrupted. If by chance 
a too strong electric current has burned out the wire, 
it will be necessary to employ small forceps to bring 
together the two extremities and, by causing a weak cur- 
rent to pass, they may be effectually welded together 
again. Finally, if it has been neglected to establish the 
stream of water before the wire loop was brought into an 
incandescent state, the light -carrier will become overheated. 
In this case, we must be cautious about too suddenly open- 
ing the stop -cock, which might result in a diminutive 
explosion and destruction of the apparatus when the water 
came into contact with the heated plates. But we must 
first let the instrument cool off before repairing the result 
of this negligence. It is a good plan when we go to 
examine a patient, especially if he is not already familiar 
with the procedure of catheterization, to anesthetize the 
urethra by means of cocaine. We employ for this purpose 
a three per cent solution, which we introduce into the 
urethra by means of an ordinary injection syringe three- 
quarters full. Oberlander uses, at the present time, in- 
stead of cocaine, a three per cent solution of eucaine. 
This anesthetic seems to have the same properties as cocaine 
without possessing its dangers. In several thousand ex- 
aminations, we have never seen any serious phenomena of 
intoxication following the injection of cocaine. At most, 
some few patients have complained of slight malaise after 
the injection. The fluid is retained in the urethra for five 
minutes and, by means of slight pressure by the finger 
along the course of the canal, it may be distributed therein. 



URETHRAL ENDOSCOPY 81 

It is to be noted, however, that the effect of the cocaine 
slightly modifies the image as seen through the urethro- 
scope. The passage of the fluid and the frictions along 
the canal may indeed cause slight superficial changes in 
the epithelium to disappear and carry away, especially, the 
the scales which cover the foci of dry infiltration. On the 
other hand, the cocaine produces a contraction of the small 
capillary vessels, so that after the injection the mucous 
membrane appears paler than it in reality is. [To avoid 
these inconveniences, we should use a local anesthetic as 
rarely as possible, and only when great hyperesthesia de- 
mands it. As a routine, we perform urethroscopy without 
it, to our and the patient's mutual satisfaction.] 

Anesthesia being thus obtained, the urethroscope tube 
is introduced. The first examination should always be 
made with a number 23. If the meatus is too small to 
admit it, a condition much more rare than one would be 
led to believe, we must either enlarge it a little or give up 
the examination, because tubes of a smaller diameter give 
a too restricted field of vision; but if the meatus is wider, 
we must nevertheless begin with a number 23; the larger 
tubes scrape the mucous membrane, destroy interesting 
epithelial lesions, or provoke, at narrow points, slight 
hemorrhages which make the examination difficult, and 
necessitate its being put off to another time. If the 
meatus permits of it, we may complete the examination 
later by the use of a tube of larger dimensions. 

To be introduced into the urethra, the tube should first 
be well covered with glycerin. When the meatus is very 
tight, we may also apply a little oil or a small quantity of 
vaselin to facilitate the passage, but fatty lubricants 
should be avoided as much as possible because they coat 
over the surface of the mucous membrane and render it 
too glistening, while glycerin may be easily removed by 
means of a small cotton-carrier. 

The urethroscope is grasped in the right hand, while 



82 CHRONIC URETHRITIS 

the left hand presses back the prepuce and gently opens 
the meatus. Once this is passed, as well as the bottom of 
the fossa navicularis, which may likewise be quite narrow, 
it is generally an easy matter to push the urethroscope as 
far as the bulbar cul-de-sac. If abnormal resistance is 
met with, due to strictures, the penis may be gently pulled 
upon with the left hand, while the tube is slowly pressed 
in; but violence must be avoided, since hemorrhages are 
caused which render the examination impossible. Once 
having reached the bulbar cul-de-sac, the obturator is 
withdrawn, then with the aid of a cotton -carrier the fluids 
which might be present in the depths of the canal are 
mopped off. The light-carrier is then introduced and fast- 
ened by means of a screw upon a projection which is on 
the flare of the urethroscope (Fig. 9) and the current is 
turned on. It is now possible to examine the urethra in its 
whole length by slowly drawing out the tube; we must, 
however, sop up from time to time, by means of a cotton- 
holder, the fluids which would otherwise make the walls of 
the canal too moist. Each time it becomes necessary to 
carry out this manipulation, the light-carrier should be first 
withdrawn. This is an annoyance and one of the incon- 
veniences of the Oberlander method. Once accustomed, 
however, the manipulation is done without trouble. [.This 
inconvenience has ceased to exist since the introduction of 
the new mignon-lamp, where mopping under light can be 
carried out.] 

To make a good examination, we must, first of all, have 
a light above reproach. The platinum wire must be fully 
incandescent; if it is simply red, the light is insufficient; 
if it is too white, it dazzles the sight. We have said that 
the extremity of the light -carrier is cut beveled so that the 
platinum wire lies on the surface inclined toward the bot- 
tom of the canal, and can not be seen by the examiner. 
If it were not closely applied to this plane, the light would 
not be hidden and would confuse the operator; if it were 



URETHRAL ENDOSCOPY 83 

applied too forcibly against the cylinder the contact of the 
latter might diminish the power of the light; one should 
also always be able to pass a sheet of paper or a thin blade 
of a knife between the wire and the plane upon which it 
rests. The urethroscope should, during the whole exam- 
ination, be kept in the axis of the canal so that all sides 
are equally visible. When it is desired to specially exam- 
ine a point upon one or the other wall, the instrument can 
be held obliquely so as to apply its extremity to the point 
to be studied. 

To examine the posterior urethra, Oberlander recom- 
mends the use of the jointed obturator with hinge -arrange- 
ment, of which we have spoken. It is, perhaps, as easy 
to use the ordinary obturator. The point of the urethro- 
scope is slowly engaged in the membranous and prostatic 
urethra in lowering gradually the flare or handle of the 
instrument, according to the ordinary rules of catheteriza- 
tion with straight instruments. The greatest gentleness 
must be employed, because the posterior urethra bleeds 
readily, and it is not always possible to avoid this incon- 
venience. The instrument being introduced up to the neck 
of the bladder, we proceed as in examination of the ante- 
rior urethra. The most interesting wall is here the inferior, 
in which the verumontanum is situated. 

[It is a source of great satisfaction to urethroscopists, 
and quite a vivid evidence of the interest manifested re- 
cently in endoscopy of the urethra, to see the efforts for 
improvement follow each other in rapid succession. The 
Nitze- Oberlander model serves as yet as a basis for all 
other modifications of such urethroscopes which contain 
the light within the extremity of the tubus. But since the 
replacing of the uncovered incandescent platinum wire of 
the Nitze- Oberlander apparatus by the almost heatless 
light of a low -tension mignon lamp of American invention 
(Koch -Preston, of Rochester), and the consequent dis- 
carding of the cumbersome cooling device, the possibilities 



84: CHRONIC URETHRITIS 

of urethroscopy have taken on rapid strides. The unpro- 
tected lamp, the encapsulated lamp, Koch's tubus having 
the light -carrier and lamp held in a small separate tube 
under the larger endoscopic tube proper, are all evolu- 
tions of the same principle toward perfection. It oc- 
curred to us, however, that one of the most salient prin- 
ciples of the Nitze-Oberlander light -carrier has been lost 
sight of in the construction of lamp -carriers. Oberlander 
has repeatedly pointed out the necessity of the light - 
source being invisible to the eye, as its presence in the 
visual line would confuse the observer. Therefore his in- 
candescent platinum wire lies on an inclined plane toward 
the bottom of the tubus. We have caused this principle 
to be applied to our modern mignon lamps, and found, to 
our regret, that at present such small lamps cannot be 
made with the desired angle, although we are trying to 
have such lamps produced. Therefore we had to give to 
the extremity of the lamp -carrier such an inclined form as 
is shown in Fig. 22 A and B. The external part of it, 
which serves as a handle, carries a knob (Fig. 22 B, Jc) on 
its lower portion which fits into a perforation (Fig. 22 A, 
2)) on the disk of the tubus, and a small pin (Fig. 22 B, 
p'), which fits into a slit (Fig. 22 A, s) on the outer cir- 
cumference of this perforation. This arrangement secures 
a handy and firm interlocking between disk and lamp- car- 
rier, serving as an immovable, firm handle (Fig. 22 A, h) . 
Thus the jerking which was caused in trying to get the 
pin or pins on the disk of the tubus enter through the 
corresponding holes on the handle of the light-carrier is 
obviated. When the shaft of the light -carrier is screwed 
into the handle part, an insulated spring (Fig. 22 B, sp) 
makes automatic contact with an insulated wire within 
the shaft, while the light -carrier itself acts as a con- 
ductor for the lamp -connection. The lamp rests on an in 
clined plane of such an obtuse angle as to be invisible to the 
eye, and yet not to encroach upon the lumen of the tubus. 



URETHRAL ENDOSCOPY 



85 



The tubus has an oxidized disk, 1% inches in diam- 
eter, preventing reflection of daylight or other extraneous 
light into the eye. The disk is provided with a perforation 
(Fig. 22 A, p) , as mentioned above, for the reception of 
the knob, and a slit (Fig. 22 A, s) on the outer margin 
of this perforation to receive the pin of the lamp -carrier 
in order to insure a firm interlocking and to act as a joint 
handle. The visceral end of the tubus is burnished to 




vp^-n;. .s.wv.^wTO^'JJ 




B 



Fig. 22. 

Weiss' Urethroscope with Lamp 
on Inclined Plane. 

A, Tube and lamp-carrier in position. 

B t Lamp-carrier with lamp on inclined plane. 



permit of forward and backward movement without again 
inserting the obturator. The stem of the obturator car- 
ries no groove, is a trifle smaller than the bore of the 
tubus lumen, and is somewhat conically elongated, thus 
making withdrawal easier and without jerking, and pre- 
venting suction, as it is not fitted perfectly air-tight, and 
air enters the moment the obturator is withdrawn.] 

We will now go over in a detailed manner the appear- 
ances of the normal mucous membrane, and the alterations 
it presents in chronic blennorrhagia. 

II. Endoscopy of the Normal Urethra. — The ap- 
pearances of the normal mucous membrane vary enor- 



86 CHRONIC URETHRITIS 

raously in different subjects, and still its characters corre 
spond quite closely to the structure of the penis. If the 
latter is small and poorly developed, the mucous membrane 
will be thin and delicate, even in robust and well -formed 
individuals; it will be particularly vulnerable in individuals 
whose glans penis, as is at times seen, is in a measure 
atrophied, or when adhesions bind it to the prepuce. 

During the endoscopic examination one is at once struck 
by the color of the membrane which naturally depends 
upon the vascularization. According as we have an anemic 
membrane, or as the vascularization is more or less abund- 
ant, the color is rosy, reddish, or bright red. Under the 
effect of cocaine it becomes slightly paler. It may also 
become markedly pale in consequence of pressure exerted 
by the endoscopic tube against the urethral walls, especially 
when it is too large for the canal, or when, being badly 
guided in the axis of the urethra, it presses forcibly upon 
one of the walls. It is always an easy matter to make out 
whether these modifications are brought about by the ex- 
amination itself, and one should guard against confounding 
them with analogous changes due to the presence of lesions 
of the mucous membrane. 

The vascularization and, therefore, the color of the 
canal not alone differ in different subjects, but present 
great variations in the same individual, according as we 
examine regions more or less deep. At the region of the 
glans, for example, the membrane is lacking in papillae and 
is poor in vessels ; thus it has a smooth appearance and seems 
much more pale than does any other portion of the canal. 
The aspect changes as soon as we reach the coronary sul- 
cus. At this point, also, the longitudinal folds begin 
which reach to the cul-de-sac of the bulb. This folding, 
analogous to that encountered in the esophagus and in 
certain portions of the intestines, is due to the fact that the 
mucous membrane which follows the marked extension of 
the penis at the time of urination and especially of ejacula- 



URETHRAL ENDOSCOPY 87 

tion, puckers up in the state of repose, forming folds 
whose number is, of necessity, in accord with the natural 
dimensions of the urethra and the structure of the penis. 
The canal presents, besides, transverse folds which permit 
of its elongation or abbreviation in following- the varia- 
tions as to the length of the penis. But when we proceed 
to the urethroscopic examination, by the slow withdrawal 
of the tube these folds are obliterated, by reason of the 
traction exerted, and are no longer distinguishable. 

All these details, however, are made out only upon an 
attentive examination, and the beginner who is experiment- 
ing with endoscopy for the first time sees only a mucous 
surface more or less red. In examining the image more 
closely, he soon perceives that this mucous surface forms a 
sort of funnel, presenting at its central part an orifice 
which is called the central figure (Gentralfigur) . This 
changes in aspect in the different regions of the urethra; in 
the region of the glans it has' the form of a small vertical 
slit, slightly rounding off in an oval shape; in the penile 
region it is punctiform, enlarging at times a little, so as to 
form a transverse opening; in the region of the bulb, and 
as we advance from this point toward the posterior urethra, 
the inferior wall of the funnel becomes more and more 
prominent according to the position of the endoscopic 
tube. The infundibuliform appearance given by the endo- 
scopic figure results from the anatomical disposition of the 
canal whose walls are, in the flaccid state, approximated 
so as to completely obliterate the lumen. At the moment 
the endoscope is passed, its walls spread out symmetrically 
at the extremity of the instrument and thus form, by the 
gaping, the appearance which we have described. It re- 
sults naturally from this that the longitudinal folds of the 
mucous membrane now appear in the form of spokes of a 
wheel, and are best marked at the central figure where the 
canal is still closed; they spread out, on the contrary, ac- 
cording as we approach the borders of the instrument; 



88 CHRONIC URETHRITIS 

they will be the more effaced the greater the caliber of the 
tube which will tend to spread them out the more com- 
pletely. The larger the urethroscope and the smaller the 
canal, the less marked will be the folds; their number 
varies from two to ten on an average. They should be 
studied carefully in healthy subjects, because chronic 
changes in the canal are accompauied by altered appear- 
ances which one must learn to recognize. 

The end of the urethroscopic tube being slightly cut 
like the mouth -piece of a flute at the expense of its upper 
portion (Fig. 9), it results that the corresponding wall of 
the urethra will be the most spread out. This mucous 
membrane well stretched is, especially in the penile region, 
traversed by reddish longitudinal strict, of more or less 
bright color, and standing out well upon a background of 
epithelium, which is paler. This striation is always to be 
found in a normal mucous membrane; it is best marked in 
a very vascular membrane, and disappears in certain path- 
ological states, as we shall see further on. Furthermore, 
the surface of the urethra is also traversed by vascular 
ramifications which, while not very numerous in anemic 
subjects, are, on the other hand, well developed in vigorous 
subjects. In the latter, at any rate, all the characteristics 
which we have just gone over are equally well marked ; 
the longitudinal folds are numerous and quite visible, the 
longitudinal striation is quite apparent, the radiations are 
of a beautiful and brilliant red, standing out well against 
a groundwork of mucous membrane which is rose -color, 
tinged slightly with yellow. 

Finally, the surface of the urethra is smooth and shiny, 
in its entire extent. We shall see later on that the slightest 
pathological changes modify this aspect; the mucous mem- 
brane becomes then irregular and loses this polish and 
brilliancy which are quite characteristic. The orifices of 
the lacunar Morgagni are visible in the entire penile and 
bulbar regions. In a verv wide canal, where the surface 



URETHRAL ENDOSCOPY 89 

forms numerous folds, these orifices may pass unperceived 
at a first examination, especially when one is not thor- 
oughly familiar with the use of the endoscope. They are 
distinguished, however, by the fact that they appear in the 
form of small points slightly excavated or dimpled, of the 
same color as the neighboring surface, or presenting a 
slightly rosy appearance; at other times they are better 
marked, and we can clearly see small orifices analogous to 
pricks made with a needle, slightly gaping. In their nor- 
mal state the borders can scarcely be said to be raised above 
the surrounding surface; from the moment they become 
really prominent, or surrounded by a red zone, pathological 
modifications come into question, about which we shall 
subsequently speak. In the normal state, too, we do not 
perceive the small glandular groups which are found in 
pathological conditions. Littre's glands are almost abso- 
lutely invisible in a canal that has never been diseased. 
Under the influence of gonorrhea, modifications occur in 
them which permit of their being clearly perceived. Once 
these lesions are formed, some change alwa3-s remains be- 
hind, and the glands remain visible even after complete 
cure. 

To resume: The normal mucous membrane appears in 
the region of the glans as a smooth surface; from this 
point to the cul-de-sac of the bulb it presents, on the con- 
trary, longitudinal folds the more marked the stronger, in 
its general construction, is the penis itself. These folds 
are quite visible with the urethroscope at the point which 
has been named the central figure, and the neighboring 
parts of the infundibulum. At points where the mucous 
membrane is well spread, the more or less characteristic 
striation can be made out, and the orifices of the Morgagni 
lacunes sought for. 

The color of the mucous membrane is not always uni- 
form; it varies in different plaques from grayish red to 
blood-red, according to the degree of vascularization. The 



90 CHRONIC URETHRITIS 

surface is uniformly smooth and shiny. The passage from 
the bulbar to the membranous region, at the external 
vesical sphincter, is always formed by the heaping up of 
mucous folds which are pressed one* against the other. We 
shall see, further on, the urethroscopic appearances of the 
posterior urethra. 

Such is the usual aspect of the urethral mucous mem- 
brane in its normal state, but all its features are more 
pronounced in a vigorous and full-blooded individual, with 
a well -developed penis; they are, on the contrary, attenuated 
in weak, anemic individuals, and in those having a small 
organ. In the latter we observe, at times, an altogether 
particular and indeed quite rare form : the mucous mem- 
brane seems thickened and pale; neither folds nor 
longitudinal striations are encountered. This appear- 
ance would suggest a lesion were it not uniform through 
the whole extent of the urethra, a condition which never 
arises from pathological change ; besides, the normal 
appearance of the glandular orifices and the very smooth 
and shiny surface of the epithelium would suffice to throw 
out this supposition. 

All the normal characteristics of the mucous membrane 
are profoundly modified in the pathologic state. 

We shall study successively the lesions of the various 
elements which constitute the canal, lesions which undergo 
ceaseless modifications from the moment a chronic urethri- 
tis begins, up to the time it attains its greatest develop- 
ment; these lesions diminish as improvement goes on, and 
disappear with the establishment of a cure. This process 
of cure may be followed, step by step, during the whole 
treatment, and is thus easily described. 

As to the evolution of the morbid process, it has evi- 
dently not been followed in the same manner, and we must 
content ourselves by describing it as it may be logically 
deduced from a study of different cases at the time they 
present themselves for treatment. 



URETHRAL ENDOSCOPY 91 

III. Endoscopy of the Pathologic Urethra— Gen- 
eral Survey. — We have seen, in a preceding chapter, 
that Neelsen considers, as the chief lesion of gonorrhoic 
urethritis, the infiltration which forms in the acute stage 
and becomes organized in the chronic period; it is to this 
chief lesion that all others which follow are attributed. 
Oberlander, in his urethroscope studies, starts from the 
same point and follows an analogous course. Thus he 
logically draws for us a complete picture of this affection, 
whose study we will begin, and successively go over all the 
details. The division of the various forms of chronic 
urethritis is made according to the more or less advanced 
degree of organization which the new-formed infiltration 
tissue has attained. Oberlander describes two chief classes. 
In the first class are placed all urethrites characterized by 
a "soft infiltration" — an infiltration which has remained 
in the embryonic state without any formation of connective- 
tissue fibers. The second includes the "hard infiltrations," 
where transformation into fibrous tissue has taken place; 
the latter is subdivided, in turn, according to the degree 
of density of the new-formed tissue and the resulting 
diminution in caliber of the urethra. In reality there 
are no different forms of gonorrhoic urethritis which cor- 
respond precisely to all these divisions, but rather there 
are successive phases of the same affection. In these dif- 
ferent periods the aspect of the diseased regions is indeed 
modified at the same time that the infiltration of the 
mucous membrane is taking place. 

Soft Infiltration. — Properly speaking, this form, which 
is characterized by the presence, within the substance of the 
mucous membrane, of an embryonic infiltration deprived of 
all fibrous element, does not belong to chronic urethritis, 
but in reality to acute urethritis. However we see, at the 
borders of regions invaded by an older lesion, the constant 
existence of a zone where the changes are recent and still 
correspond to the stage of soft infiltration. 



92 CHRONIC URETHRITIS 

The appearances it presents does not differ at all from 
those of catarrh of any mucous membrane. The surface is 
hyperemic, inflamed, and turgescent, the epithelial layer is 
swollen and slightly desquamating. 

According as the parvicellular infiltration becomes more 
dense, it becomes localized by preference about the glandu- 
lar masses; the cylindrical epithelium is transformed into 
pavement epithelium. 

If the evolution continues, connective -tissue fibres ap- 
pear in the midst of the parvicellular infiltration, and we 
pass on to the second of Oberlander's classes, that of hard 
induration. This evolution of the lesion takes place, at 
times, with such a degree of rapidity that the succession 
of the different stages escapes observation, and we find 
ourselves at once in the 'presence of hard infiltration with- 
out having recognized the stage of soft infiltration. 

Hard Infiltration. — Once we have arrived thus at the 
second stage, the infiltration is invaded more and more by 
connective tissue, and this fibrous transformation goes on 
constantly, carrying surely with it parallel changes in alL 
the elements which go to make up the wall of the urethra. 
The glands are attacked and soon play an all -important 
role, upon which we should dwell for a moment. Two 
things may happen: Either the excretory duct becomes 
obstructed by compression of the neighboring tissues or 
by retraction of its own walls, the products of secretion 
are then retained and accumulate in the gland which has 
been thus transformed into a sort of small cyst; or, on the 
contrary, the excretory duct of the glands remains per- 
meable. 

Oberlander based his description of the two forms of ure- 
thritis upon thiscriterium. Obstruction and encystment of 
the glands characterize the first variet} r : dry or follicular 
form. The second variety is the glandular form. The dry 
form is observed in about fifty per cent of cases. At times 
there exist, at the same time, cvstic zones and zones 



URETHRAL ENDOSCOPY 93 

in which the inflamed glands open into the canal; these 
urethrites constitute the "mixed forms." It is extremely 
rare that the mixed form appears at the onset before any 
treatment had been instituted. The glandular form is 
almost as frequent as the dry form. 

The urethrites of the dry form do not deserve this 
name excepting from the appearances presented by the 
mucous membrane deprived of glands; but they are not en- 
tirely without suppuration, and are almost always distin- 
guished, on the contrary, by an obstinate discharge. It is 
the very presence of these little cysts in the midst of the 
mucous membrane which impedes the circulation of the 
blood, and thus provokes various changes of nutrition, 
especially in the epithelial coating, thus making the process 
of cure a very slow one. When we treat these urethrites 
by dilatation the cysts open, become atrophic, or are de- 
stroyed; the excretory ducts of the glands becoming free, 
open outwardly, and we pass, little by little, to the mixed 
form; then to the glandular form. The treatment is 
always quite long, and can not fail to put to a severe 
test the patience of the physician as well as that of the 
patient. We have seen that chronic urethritis, properly 
speaking, begins at the moment connective -tissue fibers 
appear in the soft infiltration, and preferably about the 
glands. The process then follows a course extending over 
a more or less definite time without our being able to arrest 
it. All internal treatment, all injections and, even up to a 
certain point, all mechanical treatment prove powerless. 
We are in entire ignorance why this process begins. Once 
the lesion is formed, we know the treatment it calls for. 

At the beginning of the transformation of soft into 
hard infiltration, the appearance of connective -tissue fibers 
might pass unperceived in a urethroscopic examination, 
because of the turgescence of the mucous membrane. But 
by means of a few dilatations, the true nature of the pro- 
cess is made evident. According as the process evolves, 



94 CHRONIC URETHRITIS 

the hard infiltration spreads more and more; it will be the 
more dense and the more compact according as the soft in- 
filtration, to which it succeeds, has been dense and com- 
pact. This greater or lesser degree of density, which one 
can very clearly appreciate by the urethroscope, gives the 
degree of gravity of the case. 

According as this is more or less pronounced, we see the 
caliber of the urethra modified. If the infiltration tissue is 
not very compact the canal will preserve its normal caliber; 
this is what Oberlander calls the first degree. If the density 
is greater, this caliber will diminish; as long as endoscope, 
number 23 (15 Amer.) will pass, the infiltration belongs to 
Oberlander's second degree; and as soon as the stricture 
increases to such a point that the tube will no longer 
pass, we arrive at the third degree. 

This division is evidently quite arbitrary, but we believe 
it wise to keep to it, in the absence* of a better one, and 
for the further reason that it is very important from the 
standpoint of prognosis and treatment. The other divisions 
adopted by authors are not more rational. The first degree 
and the lighter forms of the second degree correspond to 
the wide strictures described by Otis. The forms generally 
known under the name of strictures corresponding to the 
third degree of Oberlander, as well as all infiltrations in 
reality hard, are necessarily accompanied by a diminution 
in the extensibility of the walls of the canal or, in other 
words, form a stricture. When we come to the most pro- 
nounced degrees, the infiltration tissue forms a sort of 
cuirasse surrounding the canal, and this we can very 
readily make out in palpating the latter, especially during 
dilatation, when the walls are stretched by the instrument. 
This is a convenient and practical means of gaining infor- 
mation as to the extent and thickness and, consequently, 
as to the gravity of the case. 

As we have said at the beginning of this chapter, the infil- 
tration is the primary lesion from which spring all the modi- 



URETHRAL ENDOSCOPY 95 

fieations observed in the morphological elements of the 
urethra (epithelium, glands, etc.), as well as in the func- 
tions and appearances of the canal. We must now study 
separately each one of the elements in the normal and in 
the pathological state, and we will finish with a succinct 
study of the chief morbid types described by Oberlander. 

Description of the lesions observed in the tissues: 

I. The mucous membrane with its vascularization, its 

color, its striation. 

II. Epithelium. 

III. The caliber of the canal with the central figure, 

and the fold which its walls form each time its 
caliber varies. 

IV. The glands of Littre and the lacuna? of Morgagni. 

V. The infiltration itself with its complete evolution 

from the commencement of its fibrous transfor- 
mation to the end -stage of cicatricial regression 
which marks the termination of the process. 

Description of the pathological forms: 

a. Soft infiltration. 

0. Hard infiltration. 

T -r,. , t f Glandular form. 

1. First degree. < -^ o 

° ( Dry form. 

TT . -, f Glandular form. 

II. Second degree. | Dry form 

III. Third degree. Strictures. 

The description which will follow includes all the 
typical forms of the lesions characteristic of the differ- 
ent tissues which constitute the urethra. But we must 
observe that we may find in the same canal, side by side, 
lesions belonging to different types. In other terms, 
alongside of lesions of urethritis belonging to the third 
degree we will find others belonging to the second and to 



96 CHRONIC URETHRITIS 

the first degree and even lesions of soft infiltration. We 
will also find mixed forms, for the classical forms which we 
describe are never met with in the pure state unless the 
canal has not yet been subjected to any mechanical treat- 
ment. Once it has been subjected to such treatment 
anatomical changes are produced which change the purity 
of the pathological type, and give rise to mixed forms and 
to transition forms intermediate between the types which 
we are describing. 

Description of the Lesions Met With in the Tis- 
sues of the Canal. — We have seen that chronic urethritis 
does not uniformly invade the whole extent of the canal; 
it becomes localized, on tlie contrary, in irregularly dis- 
seminated foci which are encountered chiefly in the middle 
portion, or quite anteriorly in the penile portion. Contrary 
to the opinion generally accepted, the lesions are more rare 
in the region of the bulb. In this respect examinations 
with the urethroscope can leave no doubt. It often happens, 
however, that different regions of the urethra are attacked 
at the same time. The diseased areas have very variable 
dimensions, their form is irregular, their borders are not 
clearly defined and are, little by little, passing over into the 
healthy surrounding tissues. Almost always the lesions 
are more marked and older in the center of the area than 
at the circumference, where the process seems more recent 
and appears to have a tendency to invade, in a progressive 
manner, the neighboring parts. Besides, these foci are 
frequently cut into by zones of tissue which have remained 
healthy. 

We shall now study successively the various anatomical 
elements. 

I. The Mucous Membrane.— Change of color is the first 
modification observed in the tissues of the mucous mem- 
brane at the beginning of infiltration; during the period of 
soft infiltration the mucous membrane is hyperemic and 
consequently redder than in the regions which have re 



URETHRAL ENDOSCOPY 97 

mained healthy. This color will naturally vary from deep 
rose to blood -red and even to a cyanotic red according as 
the normal mucous membrane is, as we have seen, pale 
rose, reddish, or scarlet red, 

On the contrary, the hard infiltration is characterized 
by diminution of intensity of this color. The phenomenon 
is due to the presence of fibrous tissue which strangu- 
lates the vessels and impedes the circulation. The peri- 
pheral portions of the area, in which the lesion is less 
advanced, will preserve the characters of mucous catarrh 
and will be more decidedly colored. It is so, at least, in 
cases which have not yet been subjected to dilatation 
and in which the characters have not yet disappeared about 
the zones which are the least affected. 

The pallor of the zones invaded by fibrous infiltration, 
quite marked already in the glandular forms, becomes 
altogether characteristic in the dry forms. Here the mu- 
cous membrane takes on a characteristic color, uniformly 
yellowish gray, resembling, in a measure, an eschar. This 
aspect of dead flesh disappears very slowly under treat- 
ment as the progress of cure goes on. At the same time 
that the mucous membrane, in the two forms of fibrous 
infiltration, takes on a uniform pale color, the longitudinal 
striatum which the surface normally presents, disappears 
in a more or less complete manner. In the dry form, it 
remains, at times, still visible but less distinctly outlined 
than in the normal state; it reappears slowly with the nor- 
mal color as cure takes place. 

To sum up, the mucous membrane, which is the seat 
of infiltration in the first degree, is characterized by a 
change of color and a dull appearance quite different from 
the brilliant luster of the normal membrane. The dis- 
eased areas are raised a little above the surrounding 
healthy surfaces, from which they are separated by ir- 
regularly marked limits; at the borders of the patch the 
pathological process is less advanced than in the center. 



98 CHRONIC URETHRITIS 

Cicatricial tissue is also present at times, but this belongs 
rather to the stage of regression, although we may find 
it when the lesion is still in full evolution. This cica- 
tricial tissue is met with: 

1. Surrounding the glands. 

2. In the tissue of the mucous membrane itself. 

The latter case is very rare in the light forms ; we have 
here to do with small cicatricial meshes stretching out 
over a surface of five to fifteen millimeters, or with star- 
shaped cicatrices of from one to two millimeters. In the 
dry form these cicatrices become visible only after the 
cure. We have here to deal with an exceptional lesion. 
On the contrary we see that the formation of cicatrices 
in the midst of the mucosa is the rule in those forms of in- 
filtrations which belong to the more advanced degrees. 

In the infiltration of the second degree the symptoms 
are still more manifest. The mucous membrane is pale, 
and this pallor shows up best in the urethra, whose 
normal color is a bright red, while in anemic urethrae the 
difference in color is scarcely appreciable. Around the 
pale zones appear red spots corresponding to foci of mu- 
cous catarrh with soft infiltration. These spots are only 
found in the glandular forms; the dry forms have, on the 
contrary, a uniformly gray or reddish yellow color. The 
longitudinal striation, which has disappeared in the center 
of the spots, still persists upon the borders of the latter 
and at the points where the infiltration is the least marked. 

Finally, in the center of the diseased area, at times, we 
find small granulations united in groups of one or two 
centimeters in extent, and most frequently situated on 
the inferior wall of the urethra. Their surface of gray 
or reddish yellow color, as though larded, is irregular 
and rugose; it tears and bleeds readily, especially when a 
somewhat large urethroscope is used. No glands are 
formed; these areas are, besides, of slight extent and 
altogether superficial. In the course of their evolution 



URETHRAL ENDOSCOPY 99 

they are invaded by a more or less thick connective -tissue 
hyperplasia. They are only met with in the glandular 
form; it is the same in the foci of cicatricial tissue which 
is lacking in the dry form. 

In the glandular form the appearance of the cicatrices 
depends on the thickness and extent of the infiltration 
tissue from which they spring. The superficial infiltra- 
tions produce small reticulated cicatrices, of brilliant as- 
pect, covered over with small vascular arborizations. In 
their reticulation are found healthy glands and lacunear 
depression. When the infiltration is deeper, on the other 
hand, thicker cicatricial masses are formed which at times 
fall into the opening of the urethroscope. 

In the third case, firm infiltration of the third degree, we 
can not proceed to the urethroscopic examination until there 
has been a preceding dilatation of the canal. The lesions 
are also less clearly marked. The whole diseased zone is 
uniformly pale; the longitudinal striae have disappeared, 
and reappear, little by little, upon the borders of the 
diseased areas, according as the cure progresses. At the 
same time the normal color reappears. The cicatrices, how- 
ever, preserve their pearly white aspect. When the stric- 
ture is due to an infiltration belonging to the glandular 
form, the coloration is not at all the same, as if the infiltra- 
tion would belong to the dry form. In the latter case the 
narrowed region is uniformly pale, grayish, and has a dead 
appearance. In the case of the glandular form, on the con- 
trary, the color is irregular, scattered over with red 
plaques, and made to resemble the mucous covering of 
cartilage. The normal red color comes back, little by 
little, as the cure is effected, but the membrane, even after 
a very long course of treatment, never again takes on an 
entirely normal aspect. The cicatrices found in the midst 
of the tissue of the mucous membrane during treatment, 
are distinguished by their extent, their number, their 
reticulate aspect; they at times occupy a large part of the 

LolC. 



100 CHRONIC URETHRITIS 

caliber of the canal. Along with the progress of cure, the 
color which was at first reddish, pales out little by little, 
the vascular arborizations disappear, and the cicatrices 
finally take on a fibrous and pearly appearance; they lose 
their reticulate aspect and become smooth. 

Finally, we may also find in certain cases long and deep 
cicatricial ridges, parallel to the long axis of the canal, or 
else twisting about in spiral course, and which are due to 
a sort of spontaneous scarring, developing in the infiltration 
of the mucous membrane. 

II. Epithelium. — In the healthy state, the epithelial 
coating of the mucous membrane forms a smooth, moist, 
and transparent layer of uniformly brilliant appearance. 
It possesses a luster peculiar to itself which may still 
be increased by fluids, mucus, glycerin, etc., with which 
the surface is anointed when we make a urethroscopic 
examination. If, however, we use too strong a light, or if 
the wall of the tube be freshly polished, this glitter will be 
proportionately increased, and we might think some patho- 
logical process was in question. This is an error which 
must be avoided. 

Pathologically, the epithelium becomes more brilliant 
when the most superficial regions of the mucous membrane 
are the seat of a mucous catarrh with hyperemia and embry- 
onal infiltration. At times this feature is marked in the 
whole extent of the anterior urethra; at other times, on 
the contrary, it is seen only in a few foci about the glands 
or Morgagni's lacunes. 

But most frequently, the lesions of the mucous mem- 
brane cause nutritive changes of the epithelium, which 
results in causing it to lose its transparence and glitter 
and to give to it a dull and irregular aspect, to provoke 
desquamation and even complete destruction. 

In mild instances we find only few modifications; the 
diseased surface takes on simply a dull aspect, but it re- 
mains smooth, or at least the irregularities which it may 



URETHRAL ENDOSCOPY 101 

present are too faintly marked to become very distinct. 
If an anemic mucous membrane is- in question, these slight 
nutritive modifications of the epithelium will even pass 
quite unnoticed. Its color then remains normal, but we 
may often recognize between the folds of the mucous 
membrane small hypertrophic capillary net -works which 
appear like elevations, perfectly appreciable on urethro- 
scope examination. 

Finally, when these lesions of the superficial layers of 
the mucous membrane are of long standing, the epithelium 
is thrown off and the papillary layer, now laid bare, pro- 
liferates in giving rise to small granulations analogous to 
those encountered upon the surface of cutaneous wounds, 
but much less developed than the latter. They appear in 
the form of small reddish blotches, irregularly outlined and 
with a finely granular surface which bleeds readily. 

All these lesions disappear after death, and are no 
longer recognizable upon the cadaver. 

In the more severe forms, when the mucous membrane 
is invaded by a dense infiltration which is transformed into 
fibrous tissue, the tissues become choked and the circula- 
tion is impeded. Furthermore, the nutritive disturbances 
of the epithelium are much more pronounced. We may 
distinguish different degrees: 

1. The epithelial surface has entirely lost its trans- 
parency. It takes on a roughened look clue to desquama- 
tion and to irregular regeneration of the cellular layers. 
If we apply the extremity of the urethroscope directly 
against the urethral wall, we distinctly recognize a mass of 
small, irregular elevations, quite superficial, and which do 
not give rise to hemorrhage by reason of the examination. 

2. In a more pronounced degree the preceding lesion is 
accompanied by an epithelial proliferation localized at the 
point at which the mucous membrane is most affected. It 
follows that the surface of the canal becomes irregular, 
presenting slight elevations which may reach several milli- 



102 CHRONIC URETHRITIS 

meters in height. Alongside of these are seen losses of 
substance, going clown even to the submucosa, and readily 
producing slight hemorrhages; they are of rounded form 
and have as their origin a local process of desquamation. 
The epithelial proliferation gives rise to the formation of 
plaques more or less distinctly outlined, rounded, and of 
pearly gray color. They vary in dimension— at times 
being small and thin, having the dimensions of a pin's 
head and being barely distinguishable from the neighboring 
membrane; at other times they are several millimeters 
thick, up to one centimeter in length, and remain clearly 
perceptible in the midst of the surrounding tissues. 

Finally, instead of giving rise to the formation of small 
plaques, the process of epithelial thickening may spread out 
to a much more considerable surface without finding points 
at which desquamation intervenes to cause loss of sub- 
stance. We then find upon the whole extent of the 
diseased zones a thickened epithelial layer (pachydermia) , 
and the membrane of a dull aspect, is irregular and of 
grayish color, allowing at times, by transparency, the red- 
dish color of the mucosa to show through, so that the latter 
appears as though veiled or covered with a coating of dust. 

Course and Cure. — Under the influence of appropriate 
treatment the lesions of the epithelium can, at times, 
become cured in a very short time. At other times, if the 
subjacent layers are strongly affected, the cure is much 
slower. 

In the slightest cases a cure is obtained in five or six 
days by complete reparation of the lesions. 

At a more advanced period, when the mucosa has taken 
on a rugose appearance, when we find small epithelial 
plaques which are slightly adherent and in process of 
desquamation, the irregular appearance is seen to become 
less and less perceptible under the influence of treatment 
as the underlying infiltrations become absorbed. The 
plaques of desquamation disappear, and the mucous mem- 



URETHRAL ENDOSCOPY 103 

brane becomes smooth; however, it remains for a long 
time without luster, and only takes on its shining aspect 
and normal transparency again after complete disappear- 
ance of all the other lesions. 

Finally, the more or less extensive epithelial accumula- 
tions, constituting the most marked stage of the epithelial 
lesion, begin by losing the distinctness of their features. 
The grayish spots take on, little by little, a rosy color and 
thus imperceptibly disappear at the same time that the 
mucous membrane takes on again its brilliancy and trans- 
parency. But this only occurs after complete cure of the 
underlying lesions. 

All the epithelial changes which we have described are 
scarcely met with excepting in the anterior urethra. They 
are not found in the posterior region whose epithelium is 
of a more delicate structure. 

Even in the anterior urethra these lesions are much bet- 
ter marked when the canal is of a vigorous structure and 
the mucous membrane well supplied with blood. All the 
changes which the latter undergo are then well marked; 
while in anemic subjects thej r are less noticeable. Besides, 
if we examine for the first time a patient, who has already 
undergone treatment by means of sounds or bougies, the 
characters of the epithelial lesions are no longer so plain, 
although they may still be far from normal. Generally we 
find the surface of the lesions dull and nearly smooth, the 
epithelium having lost its transparency. This condition 
may persist for a long time. 

We may further meet with two kinds of quite special 
lesions when it is a question of urethritis already subjected 
to treatment. We will describe them here: 

1. These are eschars due to injections. The salts of 
zinc produce small white eschai-s from one to two milli- 
meters in extent, which are found at the summit of mucous 
folds and which may persist for one or two weeks. 
Resorcin injections produce a sort of grayish white 



104 CHRONIC URETHRITIS 

shriveling which is irregular and extends over a certain 
extent of the canal. Finally, nitrate of silver gives to the 
mucous membrane a uniformly whitish aspect as if it were 
covered with a layer of dust. 

2. Argyrosis is produced by the prolonged use of 
nitrate of silver. This salt is deposited in the epithelial 
layers and here gives rise to the production of bluish or 
blackish irregular plaques resembling little ink spots par- 
tially effaced. These are met with especially in the bulbar 
or in the penile portion. Or the argyria is localized at the 
orifices of the glands or lacunae; here it produces small 
black circles. It may persist for years without any incon- 
venience. 

III. The Folds. — The longitudinal folds which the 
urethral mucous membrane forms when it is more or less 
completely reflected upon itself, appears upon urethroscopic 
examination in the form of the radiating spokes of a wheel. 
They are the more numerous the larger the normal caliber 
of the canal; they unite in the center of the endoscopic 
image to form the central figure. We have seen that this 
central figure in the region of the glans penis has the 
appearance of an oval slit with its axis vertical. In the 
penile portion it appears in the form of a small pit, en- 
larging at times so as to form a transverse opening. In 
the region of the bulb the endoscopic figure is no longer 
regular, the lower wall projects decidedly, and when we 
come to the membraneous region, the upper wall scarcely 
appears any longer than a small surface distributed with 
what seem to be decidedly stretched folds. 

It is in the neighborhood of the central figure that we 
best see the folds of the mucous membrane and can study 
their characters. They differ, however, very much accord- 
ing to the dimensions of the urethra and also according to 
whether we use a large endoscope whose introduction into 
the canal has the result of effacing them. 

When the mucous membrane is diseased, its characters 



URETHRAL ENDOSCOPY 105 

of extensibility and elasticity being considerably modified, 
we should necessarily find parallel modifications in the 
folds which it forms. 

In simple mucous catarrh the mucous membrane is uni- 
formly thickened, the folds are larger, thicker, and less 
numerous than in the normal state; there are not over two 
or three, and these jut forth into the lumen of the canal so 
as to obstruct a view of the central figure. 

1. In the first stage of hard infiltration their number 
diminishes notably; they even disappear in the dry form, 
while some still exist in the glandular form. Their com- 
plete disappearance in the latter corresponds to the begin- 
ning of the second degree. Under treatment the folds re- 
appear slowly, here and there interrupted by periglandular 
infiltrations which may persist. 

2. In the forms of hard infiltration of the second group 
the folds of the mucous membrane have wholly disap- 
peared, at least in the midst of the patches; they may still 
be visible at the limits of the diseased zones where, as we 
have seen, the lesions are always less advanced. However, 
when the infiltration is not very dense, the surface of the 
mucous membrane, even in the center of plaques, does 
not appear absolute^ smooth; it presents certain eleva- 
tions which vaguely recall the folds of normal membrane. 
On the other hand, when the infiltration is very dense, the 
canal forms a sort of rigid tube which remains wide open 
when the urethroscope is withdrawn; then the folds, as 
well as the funnel which they form, and the central figure 
have completely disappeared. 

When a cure is brought about it first shows at the peri- 
phery of the lesions where the broad rough folds appear; 
then it extends, little by little, to the whole diseased sur- 
face; but the folds only exceptionally take on again all 
of their former suppleness; there always remains, at least 
in their distribution, a certain rigidity which is found 
constantly. 



106 CHRONIC URETHRITIS 

3. The forms of hard infiltration which belong to the 
third group can be examined only after dilatation has been 
accomplished. We then see a sort of large and irregular 
folding progressively to reappear, which persists for a long 
time, and the folds which form after complete cure no 
longer present the extreme delicacy which characterizes 
the normal state. The infiltrations which belong to the 
purely simple dry form, however, again have quite fine 
folds when they have come to a state of complete cure. 
At the periphery of the areas the lesions are less pro- 
nounced and belong to the first or second degree;, they 
behave as we have seen before. 

IV. Glands and Lacunce of Morgagni. — We have seen in 
studying the normal anatomy of the uretha, that we meet 
with quite numerous glands which may be divided into two 
classes: 

The first class comprises isolated follicles which are 
invisible to the naked eye. These are without interest in 
endoscopic study. 

The second class includes Littre glands or agglomerated 
acini, which are at times situated immediately below the 
epithelial surface of the mucous membrane; at other 
times much more deeply in the mucosa and even in the 
midst of the spongy tissue. 

They vary in number and are not located at the same 
depth in the mucous membrane of all individuals. They 
unite in more or less compact groups. This contributes 
to emphasize the individual differences of the normal 
urethra, and to impress a peculiar character upon the 
course which gonorrhoic infection pursues in different 
patients. These glandular agglomerations are rarely visible 
in the normal state, in spite of their being very numerous 
and superficially situated. When they are situated within 
the mucous membrane they are not perceived unless they 
become diseased. 

In the pathological state it is a rare thing for them to 



URETHRAL ENDOSCOPY 107 

"be found isolated. They are in groups of four or five, 
forming- at times thirty or forty small lenticular plaques 
which are especially noticeable because of the destruction 
of the superficial parts which cover them. At times, 
liowever, this covering, instead of being destroyed, per- 
sists, becomes thickened, and the whole evolution of the 
process remains hidden within the mucous tissue. 

Finally, it may happen that the excretory ducts alone 
appear diseased on examination, in the absence of all 
glandular lesion properly so called. They then show them- 
selves under the form of scarcely visible small impressions 
or indentations, of the same color as the neighboring tissues, 
and which are clearly made out in an oblique light by 
inclining the endoscopic tube laterally. We are confronted 
in this case with a lesion in process of cure, with a gland- 
ular inflammation of which there remains only a few traces 
and which is localized at the excretory ducts alone. In 
studying the lesions observed in Littre's glands, we see 
that these glands may either present only a simple mucous 
swelling, or else be invaded by a process of inflammatory 
infiltration, or still again, as we have already stated, their 
lesions may remain subepithelial and the whole process 
to have occurred in the mucosa itself. 

a. Mucous catarrh, simple, is accompanied by an in- 
•crease in the glandular secretion. This lesion usually char- 
acterizes the lightest forms of chronic urethritis, and is 
met with especially upon mucous membranes of very deli- 
cate structure. It, at times, accompanies the forms with 
well-marked hard infiltration, but then we would find it 
outside the bounds of the invaded areas, at the points 
where they are separated from the healthy tissue by a zone 
with slightly marked lesions; finally we meet with it in 
small isolated foci and surrounded by other foci of more 
■deeply situated and older lesions. When Littre's glands 
present lesions of this form, the mucous membrane which 
covers them is pale red and slightly puffed out, the excre- 



108 CHRONIC URETHRITIS 

tory ducts, without being exactly dilated, remain, however, 
quite visible to the educated eye, and the neighboring" 
membrane is slightly swollen. Besides, these lesions per- 
sist for a short time and may radically be cured. 

b. Chronic inflammation is the lesion most frequently 
encountered. It is characterized by a fibrous infiltration 
of the glandular tissue and of the excretory duct, from 
which results an increase in volume which appears as a 
hypertrophy of the gland. The excretory duct becomes 
widely gaping. 

This lesion, according to the conditions of individual 
resistance of the structure of the urethra, and the violence 
of infection, may invade the glands over a greater or less 
extent of the canal. At one time, in going over the whole 
urethra, we will meet with only a few glands decidedly 
swollen; at other times, on the contrary, we may encounter 
a large number of small glands which have attained a de- 
velopment much less considerable; or perhaps a mixture of 
these two forms. They may, besides, acquire a very con- 
siderable volume — one reaching such a degree that they 
might be confounded with the lacunae of Morgagni if their 
number were not sufficient to render this mistake impos- 
sible. Their excretory duct, in the mildest cases, may 
appear as a scarcely discernible red point, still covered 
with a very thin, transparent film formed by the epithelial 
and connective layers of the mucous membrane. 

Generally this covering is destroyed and the duct is laid 
bare, at least in its most superficial part. The borders are 
surrounded by a red zone and are raised above the surface, 
when the infiltration is well marked, above the level of the 
neighboriug mucous membrane. The lumen is gaping, form- 
ing a small indentation surrounded by a bright red zone 
where the mucous membrane is congested and prominent. 
At times we may meet with a slight blood -effusion which 
forms a small blackish circle around the glandular orifice. 
But generally this blackish circle, when it exists, is due to 



URETHRAL ENDOSCOPY 109 

a local argyria which may affect this situation by prefer- 
ence, and persist here for several weeks. 

Left to themselves, these lesions, by reason of the pro- 
gressive invasion of the fibrous tissue, are little by little 
transformed, the gland becomes destroyed, leaving behind 
a circular connective -tissue cicatrix which then resists all 
attempts at treatment. In this case the orifice of the ex- 
cretory duct remains widely open, but its borders become 
effaced, lose their bright red color and disappear in the 
surrounding tissue. Having reached this stage the glands 
of Littre remain indefinitely in the same condition. We 
find, at times, examples of this variety of glandular hyper- 
trophy in cured urethras in the midst of cicatrices which 
have become indifferent (todte Narben) . Oberlander does 
not regard them as pathologic. 

Subjected to treatment by dilatation, the glands, 
little by little, reassume their normal appearance; they 
appear first less numerous in regaining their struc- 
ture and their physiologic function; only the epithelial 
covering, destroyed by the disease, naturally does not 
form again. As to the glands which have greatly in- 
creased in size under the influence of infiltration (hyper- 
trophy), their cure takes place very slowly; it is often 
only after complete disappearance of all the other lesions 
that we see their gaping orifices gradually disappear. 
These orifices may even remain in the same condition 
despite all treatment. Furthermore, the glands continue 
to secrete even when they are in full morbid evolution, 
and the urinary filaments characteristic of gonorrhea 
are often nothing else than the result of this pathalogic 
activity. 

But the glands of Littre, instead of occupying a super- 
ficial situation, can, on the contrary, be located more 
deeply in the mucous membrane and, consequently, cov- 
ered over by a quite considerable thickness of tissue which 
the pathological process invades without destroying. The 



110 CHRONIC URETHRITIS 

inflammatory infiltration then brings about changes in the 
tissue of the gland and in the excretory canal, which we 
have already described; the excretory canal, however, be- 
comes obstructed from the swelling of its walls and of the 
tissues covering it. 

In this case, in examining the diseased regions, fre- 
quently no glandular orifices, or only very few, are seen, 
because all the glands are not situated at the same depth; 
some .being more superficial may remain quite visible and 
pass through their evolution, as we have already seen. 
When the excretory duct is thus obstructed, the gland 
itself becomes dilated and forms a small cyst of variable 
course according to the intensity of the process. When 
this is an acute one a small follicular abscess forms 
which evacuates on the surface of the membrane or, at other 
times, in the depths of the tissues themselves. When the 
process is less acute, instead of pus the cyst contains a 
colloid material. Little by little the excretory duct becomes 
again permeable. Generally, according to Oberlander, the 
cysts rupture into the surrounding connective tissue, and 
their products are resorbed. With a process still less acute, 
corresponds the formation of small cysts, which swell up 
only a little, do not open, and inevitably undergo subse- 
quent cicatricial atrophy. 

This form of chronic gonorrhea to which Oberlander 
has given the name of dry or follicular urethritis, is readily 
distinguished on endoscopic examination. When the 
diseased glands are relatively quite superficial and are 
found almost immediately beneath the epithelium, they pro- 
ject on the surface of the canal in the form of small r 
transparent vesicles which may reach the diameter of a 
hemp -seed. They are the less prominent the deeper in 
the midst of the mucous membranes they are located. The 
depth may be such that the glandular cysts no longer 
appear upon the surface, and their presence, owing to the 
compression which they exercise upon the superficial capil- 



URETHRAL ENDOSCOPY 111 

laries, is no longer shown except by a diminution of the 
color of the mucous membrane. We then find small, 
paler points; the mucous membrane which encloses the 
cysts seems rigid and does not fall into folds like healthy 
membrane, but appears withered and colorless. 

We shall see, later on, that these dry forms of chronic 
urethritis are characterized by a tenacious and persistent 
suppuration, and that they are particularly rebellious to all 
treatment. To obtain a cure we must employ dilatation 
with patience and for a long time; and this treatment is 
the more indispensable as gonococci, whose virulence is 
not yet destroyed, may exist locked up in the cysts. 

The lesious which we have just described are scarcely 
observed excepting in the anterior urethra, where the 
glands of Littre are particularly numerous aud well de- 
veloped. In the posterior urethra these glands are much 
less numerous aud even at times are wholly absent. We 
have often observed them in the membraneous region, rarely 
in the region of the prostate; they are always of a much 
smaller volume, their excretory canal is extremely short, 
and their situation is very superficial. In chronic inflam- 
mation of this region they play a much less important role. 

This is the chief reason why simple chronic posterior 
urethritis is much rarer than it is generally considered, 
and why it resists treatment a much shorter time than 
anterior urethritis. In reality, when posterior urethritis 
becomes tenacious and persistent it is because it is accom- 
ganied by prostatitis, by spermatocystitis, or by other 
deep-seated complications which we must overcome before 
we can obtain a cure of the urethra. 

To resume: The lesions of Littre' s glands characterize 
very well the different forms of chronic urethritis which we 
have mentioned at the beginning of this chapter; they 
have, furthermore, served in a measure as a basis for the 
classification which we have adopted. To recapitulate, 
this is what we find in the different degrees of urethritis: 



112 CHRONIC URETHRITIS 

A. Soft Infiltration.— The glands of Littre do not 
show any appreciable lesion. 

B. Hard Infiltration. — First Degree; Glandular Form. 
— The glands present only faintly marked lesions. We see 
them at times united in small groups, the borders a little 
redder than the surrounding tissue, are slightly swollen and 
surrounded by a red zone. The gland itself is surrounded 
by a zone of quite superficial infiltration which is scarcely 
visible even about the excretory duct. When cure has been 
effected we see the characteristic redness slowly disappear 
at the same time that the zone of peripheric infiltration is 
absorbed ; this zone may, however, persist for quite a 
long time, especially when the infiltration tissue is quite 
dense. Cure is more rapid in the lower wall of the 
urethra; in the upper wall, on the contrary, it is slower, 
and it is upon this surface that we must always search for 
the last traces of the lesion. 

Dry Form. — In this form the excretory ducts are entirely 
invisible, the membrane being occasionally scattered with 
small vesicles. When cure has resulted from dilatations, 
either the excretory duct opens again, or the glandular 
body ruptures within the tissue of the mucous membrane. 
This phase of the process is quite fugacious, but eventually 
a cure takes place. At times there remain after treatment 
a few follicles which are without importance so far as the 
cure is concerned. Cicatrices may also appear on the sur- 
face of the mucous membrane in the neighborhood of, but 
not immediately around, the excretory duct. 

Second Degree; Glandular Form. — The diseased glands 
are always united in quite compact groups. Those which 
are situated in the center of these groups are the most 
severely attacked and are found more or less Irypertro- 
phied. Their excretory duct is generally swollen and sur- 
rounded by a reddish inflammatory zone. The glands them- 
selves are swollen and surrounded by a zone of prominent 
infiltration. 



URETHRAL ENDOSCOPY 113 

It is very interesting at times to follow the process 
of cure. The glands then appear in consequence of the 
absorption of the infiltration which covers them, under the 
form of small glassy prominences, they are open and 
their contents are eliminated. The orifice by which this 
elimination is effected remains at times visible for a short 
time only; at other times this orifice persists for a long* 
time, even after complete cure of the lesions of the 
neighborhood, and forms a sort of cup -like depression 
which can be emptied through pressure exerted by means 
of a pointed probe. 

The lower wall of the canal is particularly the seat of 
this glandular hypertrophy. We will meet similar lesions 
in the lacunaa of Morgagni, and notice that they are 
situated with preference on the upper wall of the canal. 
Finally, after complete cure, the dead cicatrices still 
enclose a certain number of glandular groups which have 
remained visible. 

Dry Form. — In this form the glands are never seen 
united into groups, and we meet with large surfaces over 
which they are invisible. The few glandular orifices which 
we perceive are quite frequently surrounded by cicatricial 
tissue. Following dilatations, we see this cicatricial tissue 
disappear, and the glandular orifices are found to be much 
more numerous and present a normal aspect without inflam- 
matory lesions. There is also transition into the mixed 
form. At other times they rupture within the tissues and 
their contents are absorbed. As to the follicles which do 
not open, they may become completely encapsulated in 
fibrous tissue and thus become innocuous. 

The lacunce Morgagni present close analogies to the 
glands of Littre in form, nature, and endoscopic aspect of 
the lesions which one encounters. In the normal state 
and in a urethra of medium caliber, we perceive quite dis- 
tinctly their orifices under the form of small pricks, like 
those from a needle and slightly open. They are of the 



114 CHRONIC URETHRITIS 

same color as the neighboring mucous membrane, or per- 
haps a little deeper colored, and at times we may perceive 
their oblique direction through the mucous membrane. In 
very vascular canals of large dimensions, aud hidden be- 
tween well-marked folds, the presence of lacunae at times 
escape being seen on examination because they remain 
hidden between the folds of the mucous membrane. 
Finally, when the urethral mucous membrane is pale, 
they may also escape attention because of insufficient 
color. They are situated upon the superior wall, or upon 
the lateral walls of the urethra, where we find from three 
to eight of them. If we think, at times, that there are 
many more than these, or if they appear united in groups, 
there has been a mistake made in confounding them with 
the glands of Littre, which have become visible through 
pathological changes. 

In the same way as the Littre glands, the lacunae of 
Morgagni may present pathologically different forms. 
They may, like the former, be affected with simple mucous 
catarrh, or else be invaded by infiltration, with the simple 
difference that the elements are of greater size, and that 
their changes are more clearly visible and more marked. 
The lacunae swell up, take on a deeper color, which is the 
more noticeable the paler the surrounding mucous mem- 
brane. The borders of the orifice also swell and take on a 
glassy aspect, then disappear as the infiltration becomes 
more marked and interferes with the neighboring circula- 
tion. The lacunar tumefaction forms at the surface of the 
mucous membrane a prominence which may reach the di- 
mensions of a pea. Generally it appears as a nodule of 
the size of a pin's head, of red or of deep red color, on 
the summit or the sides of which we discover the orifice 
with borders swollen and translucid, throwing out, at 
times, products of mucous and purulent secretion. All of 
these details are seen less readily in a very large canal with 
mucous membrane well colored and with numerous folds, 



URETHRAL ENDOSCOPY 115 

whose swelling masks that of the lacunae; but the com- 
pression exerted upon the neighboring vessels by the infil- 
tration is then shown under the form of a small, pale, su- 
perficial macule. The evolution of the process is again 
analogous to what we have already seen at the Littre 
glands. The simple mucous catarrh may heal spontane- 
ously, followed by restitutio ad integrum; but this fortu- 
nate result is rarely seen. 

Generally the inflammation of the lacuna of Morgagni 
is accompanied by infiltration, at times even by suppura- 
tion; and in these two instances the process always ends 
in a more or less complete destruction of the anatomical 
elements. At times the orifice of the lacuna remains widely 
open and gaping in the midst of a red areola, and if it is 
not obstructed by products of secretion, it permits one to 
see quite distinctly the cavity of the lacuna itself, which 
is red and inflamed. At other times, as the retraction of 
the newly formed fibrous tissue takes place, the orifice 
contracts until it now forms a bright red point in the 
midst of surrounding sclerosed and pale tissue; it then 
absolutely resembles the orifice of a Littre gland. 

Finally the sclerosis may appear quite clearly at the 
surface, and we see the orifice of the lacuna circumscribed 
by cicatricial fibrillae radiating in every direction. Under 
the influence of dilatation, the orifice, now swollen and 
gaping, diminishes progressively in volume, becomes pale, 
and closes up little by little. At times it tears and is trans- 
formed into a fissure in the bottom of which one sees 
small, bright red points corresponding to the infiltrated 
orifices of the Littre glands which open in the lacunar 
cavity. At other times the lacuna ruptures and throws out 
its contents into the canal, but this is the exception. 

The orifice may also become obstructed by cicatriza- 
tion and give rise to the formation of cysts analogous to 
those of Littre's glands, constituting small red tumors 
standing out bevond the surface of the mucous mem- 



116 CHRONIC URETHRITIS 

brane. Upon their summit there is to be seen at times 
a diminutive depression, but the orifice is generally in- 
visible. 

As the process goes through its evolution and becomes 
less acute, the swelling diminishes and the nodosity thus 
formed becomes less visible — it is lost in the tissues of the 
mucous membrane. The appearance is then similar to that 
which we have seen in the same phase of the process in the 
glands of Littre: dry, follicular urethritis; discolored mu- 
cous membrane; cadaveric aspect. This phase may per- 
sist for a long time in spite of treatment. In palpating 
the urethra after a dilator has been introduced, we may 
feel the nodosities in the form of small hard points, 
somewhat rounded, disseminated in the midst of infiltra- 
tion tissue. Thus slowly the contents of the cyst become 
condensed and the tissue, as a whole, atrophies, smothered, 
as it were, in fibrous retraction. This is the ordinary pro- 
cess of cure. Finally, dilatation can result in causing the 
cyst to burst upon the surface of the mucous membrane. 
There thus forms an excavation which is larger or smaller, 
according to circumstances, with detached border, and with 
bleeding surface which cicatricizes rapidly. Rarely can we 
perceive a similar evolution whose duration is very short, 
and which Oberlander himself has only observed about ten 
times. The complete and definite destruction of the lacunae 
is the necessary consequence. 

Cicatrices of the Urethra. — We have seen that chronic 
urethritis is cured by absorption of the products of infiltra- 
tion of the mucous membrane. But it often happens that 
this absorption is not complete; foci may remain which 
often undergo complete evolution and are transformed into 
cicatricial tissue. This, in a certain way, is another form 
of cure. Such a transformation may be spontaneous, but 
requires an exceedingly long period of time to take effect; 
it takes place with much greater rapidity under the influ- 
ence of treatment. 



URETHRAL ENDOSCOPY 117 

Such a cicatrix of the mucous membrane has the struc- 
ture of typical cicatricial tissue; it is composed wholly of 
connective-tissue fibers, does no longer include any embry- 
onic elements and is not capable of giving rise to recur- 
rences of urethritis. When it begins to appear, we dis- 
tinctly make out small fibrous bands, but in the terminal 
stage, it is entirely smooth, has no reticular appearance, 
and should be covered over with epithelium which is 
smooth and brilliant. This condition can always be dis- 
tinguished by means of the endoscope, because it is less 
elastic than the normal tissue of the urethra, and the 
lumen of the canal remains patulous when, in withdrawing 
the urethroscopic tube, we traverse a zone where it pre- 
dominates. 

In other most simple forms such as are met with at 
times in the mucous membrane after cure of the soft in- 
filtration, the linear or star -shaped cicatrices are only a 
few millimeters long and about one millimeter broad; 
they are distinguished by their pallor which makes them 
appear white in the midst of an anemic mucous surface, 
whitish, red, or yellowish when situated in a mucous sur- 
face which is highly vascular. This form is very rare. 

Analogous cicatrices are met with also in the midst of 
zones of fibrous infiltration. They are often visible during 
the course of treatment; their number is also more con- 
siderable than in soft infiltrations. They may be accom- 
panied by other cicatrices developed around the orifices of 
the Morgagni lacunae and surrounding glandular orifices, 
but not in the immediate neighborhood of the latter as 
we have already stated in the previous chapter. 

If the cure of soft infiltration can be accompanied by 
the formation of small cicatrices, there is all the more 
reason for its occurrence in hard infiltrations. When the 
latter are neither too dense, nor too deeply situated, we 
can, it is true, set up bj' dilatation complete resorption; 
but when once there is extensive infiltrations, invading 



118 CHRONIC URETHRITIS 

deeply the walls of the canal, complete absorption is no 
longer possible even by a prolonged course of treatment. 
A cure can no longer be produced, excepting by at least 
a partial transformation of the inflammatory tissue into 
cicatricial tissue. 

These cicatrices appear at first under the form of 
trabecule, between whose meshes the remains of granular 
tissue often still persists; or as infiltrated glands and 
lacunas and vascular arborizations of variable form and 
extent; they have a peculiar grayish brilliant color. By 
means of dilatation we, little by little, set up resorption of 
all embryonic tissue which they enclose; the cicatrices 
diminish in extent, become paler, are effaced and disappear 
at times in a progressive manner. But the large masses of 
infiltration occupy at times the semi-circumference of the 
urethra or more, persisting even until after a complete 
cure has been affected, and remain indelible. We find them 
on the lower wall of the canal, while small cicatrices, of 
which we have already spoken with reference to the glands 
and the lacunae, naturally are found rather upon the upper 
wall. When they are no longer composed wholly of other 
than purely cicatricial tissue, no longer enclosing infil- 
tration elements, they are called dead or indifferent cica- 
trices. (Oberlauder) . They are often absolutely smooth, 
brilliant, and covered over with a quite uniform epi- 
thelium. They no longer present any apparent trabec- 
ular structure and are directly continuous with the neigh- 
boring tissues without any visible protrusion. 

Special Description op the Various Forms of 
Chronic Urethritis. — We have seen, successively, the 
chief lesions which the anatomic elements of the urethra 
present in the course of a chronic gonorrhea; we have 
also studied the appearances which these lesions present, 
and in what manner one may make the diagnosis by means 
of urethroscopic examination. We shall now pass in re- 
view some of the typical forms corresponding to the classes 



URETHRAL ENDOSCOPY 119 

which we have established; but we will draw attention to 
the fact that it is rare in practice to encounter entirely pure 
forms. While the most important lesions which are seen 
in a given case correspond, as a rule, quite closely to one of 
the types described, we will find alongside of these lesions 
which are somewhat secondary, and which cannot be at all 
attributed to the particular type. The course and form of 
chronic urethritis depends upon so many factors that we 
easily explain this absence of parallelism between the 
nature and evolution of the lesions which we may find in 
the same patient. 

Soft Infiltration. — We have to deal here with simple 
parvicellular infiltration, attacking slowly the mucous 
membrane; hence the name mucous urethritis which Ober- 
lander has given to it; and here we never meet with 
diminution in the caliber of the urethra. This permits us 
a priori to exclude this form, if the endoscopic tube nor- 
mally introduced into the canal is arrested at any point of 
its course. 

It is met with by preference in the most anterior por- 
tions of the penile urethra; it is more rarely localized at 
the bulb; and in the region of the glans it is recognized with 
great difficulty. It appears, in general, a short time after 
infection, when the acute period has passed through a 
relatively benign evolution. It passes unnoticed, on the 
contrary, under the influence of a very virulent infection, 
when the infiltration has invaded the deep tissues, or else 
when we have to do with quite delicate mucous membranes 
in w T hich the infiltration readily passes from a torpid into a 
chronic form. 

Through the endoscope the mucosa appears red and 
inflamed. A fact which immediately distinguishes this 
form from the hard infiltration is that the mucous mem- 
brane becomes paler under the influence of a vascular com- 
pression exerted by the fibrous tissue. The red color will 
be the more marked the more vascular is the mucous mem- 



120 CHRONIC URETHRITIS 

brane normally, furthermore, the normal striations dis- 
appear completely in the midst of a generalized redness, 
or we see it only more or less at the borders of the inflamed 
zones; it reappears rapidly as cure takes place. 

The epithelial surface then takes on a more brilliant 
aspect, as we have indicated in in the chapter treating on 
this point; then, according as the infiltration progresses, 
it loses little by little its polished surface, becomes opaque 
and finally becomes roughened when desquamation be- 
gins. It nevertheless always preserves its normal trans- 
lucency. Once the latter becomes modified, it is a certain 
sign that there are severe lesions in the body of the 
mucous tissues. The various epithelial lesions which we 
have just described are found side by side upon the sur- 
face of the same plaque of infiltration, and may disappear 
in a few days with the greatest ease. 

Finally it sometimes happens that the epithelium be- 
comes completely desquamated and reveals the surface of 
the membrane and its papillae, thus giving rise to a small 
granular plaque which is in reality an excoriation that 
bleeds upon contact with the urethroscope. The cure of 
these small plaques is rapidly accomplished. 

The longitudinal folds of the canal swell up, as does the 
whole mucous surface, and are thus less numerous than in 
the neighboring portions. We meet with three or four 
large red folds in the midst of numerous thin folds which 
form in another part of the normal mucous membrane; or 
the upper wall of the canal occupies the whole endoscopic 
field with one large prominent lacuna, while the lower wall 
is no longer seen. At other times the canal becomes very 
decidedly narrow, the folds which were few in the normal 
state are no longer at all visible, and the membrane appears 
only smooth, red, and swollen. 

That which distinguishes in a definite manner the soft 
infiltration from the other forms of urethritis with hard 
infiltration is the fact that the mucous membrane never has 



URETHRAL ENDOSCOPY 121 

the feature of dryness and rigidity which distinguishes the 
latter; the central figure also never remains gaping but 
always closed immediately upon the withdrawal of the 
endoscope. 

Lift re's glands are scarcely affected, or at least their 
lesions are not visible because they remain covered over 
with an epithelial and subepithelial layer, whose destruc- 
tion cannot take place except under the influence of a much 
more intense inflammatory process than that which charac- 
terizes a mucous urethritis. 

As to the lacunoB of Morgagtii, the catarrh which affects 
them is characterized by swelling and deep color which 
stands out in contrast, to the neighboring mucous mem- 
brane. Their swollen orifices have borders of a glassy ap- 
pearance and become indistinguishable by degrees, accord- 
ing to the density of the infiltration which takes place. 
The neighboring circulation is impeded. 

This lacunar tumefaction thus forms upon the surface 
of the mucous membrane a projection which may reach the 
dimensions of a small pea. It generally appears as a red 
nodule of pin size upon whose summit, or on the side of 
which, we find the orifices whose borders are swollen and 
translucid, and through which at times are thrown off 
the products of mucous or purulent secretion. These 
nodules are less apparent in a highly colored urethra whose 
numerous folds are swelled and so mask the swelling of the 
lacunae; but then the compression which the exudate exerts 
upon the neighboring vessels is shown in the form of small, 
pale superficial macules. We must, however, observe that 
these lesions of the lacuna of Morgagni are rare in simple 
catarrhal urethritis and, on the contrary, frequent in 
the hard forms. We must always be on guard, also, because 
of their presence in the midst of the zone of soft infiltra- 
tion, that which causes us to suspect beneath the latter 
the existence of more severe lesions hidden b} r the benign 
superficial ones. 



122 CHRONIC URETHRITIS 

Clinical Details, Course, Cure. — Mucous urethritis shows 
itself about five or six weeks after the beginning of the in- 
fection; it is generally well cured by means of the usual 
injections. Dilatation carefully carried out, as soon as the 
acute phenomena disappear, gives the best results. After 
the first or second one, the inflammatory redness and mucous 
swelling disappear; the desquamative lesions of epithelium 
are somewhat resistant, but get well in a complete manner 
after a few weeks. Finally, when the cure seems complete 
we may still perceive some swollen lacunae appearing upon 
the surface of the membrane under the form of small prom- 
inent points of pin -head size, above which the epithelium is 
hazy and irregular. A few supplementary dilatations are 
often necessary to assure their disappearance. Finally we 
must not forget that in the midst of zones of soft infiltra- 
tion masked by mucous swelling, nodules of hard infiltra- 
tion may be found, whose presence is only made out after 
the cure of the more superficial catarrhal lesion. These 
nodules are naturally of small dimensions, but they require 
a longer and more energetic treatment and we must know 
beforehand regarding this in order that we should not be 
taken unawares by their sudden and unexpected appearance. 

Hard Infiltrations. — As their name indicates, the forms 
of infiltrations comprised under this denomination are dis- 
tinguished by their hardness; the walls of the urethra, 
which are extremely elastic in the normal state lose this 
quality as soon as they are invaded by a fibrous infiltration, 
and this the more completely the greater the density of 
the fibrous tissue. 

In light forms this hardness will be scarcely perceived 
or will be but imperfectly made out, while in the most pro- 
nounced forms the walls lose all of their elasticity and 
become resistant and cartilaginous. When we examine the 
canal we see that the hardened walls are no longer in folds 
as in the normal urethra, and the central figure, instead of 
closing as the endoscope is withdrawn, remains widely 



URETHRAL ENDOSCOPY 123 

gaping. The hard infiltrations never invade the urethra in 
a uniform manner; the}- have variable dimensions accord- 
ing to the extent of the zones where chronic inflammation 
has persisted. They penetrate more or less into the depth 
of the tissues, are interspersed with healthy tissue, and 
finally present cicatrices which we have already studied. 
Oberlander divides the hard or fibrous infiltrations into 
three groups according as the caliber of the urethra re- 
mains normal, or is narrowed more or less below 23 Char- 
riere. This division is purely arbitrary, and the classical 
cases which we shall now describe are not met with in 
practice excepting when the examination of the canal can 
be made before any treatment has been begun. Once 
treatment has commenced, the endoscopic appearance of the 
urethra frequently changes; new foci of infiltration appear 
at points which seem to be healthy; old foci may continue 
to extend in depth without our being able to arrest the 
process. 

At other times acute recurrences come up in the midst 
of the chronic state. Foci thus appear whose existence 
had not previously been expected; at the same time foci of 
acute inflammation may show themselves in the midst of 
zones attacked with chronic inflammation and, by prefer- 
ence, in glandular masses. These glands enter into a state 
of suppuration, and at times undergo complete puruleni 
disintegration. 

Recurrence is also frequent even during the course of 
treatment. Finally cure is brought about by slow disap- 
pearance of the lesion, or by transformation into cicatrices. 
Perhaps this cure is spontaneous. It is difficult to give an 
opinion upon this point. Patients who are not carefully 
treated are always exposed to recurrences; they generally 
exhibit a state of contagiousness, and may transmit their 
gonorrhea; finally they are threatened with all the usual 
accidents of ascending infections and strictures of the 
urethra. 



124 CHRONIC URETHRITIS 

Cure takes place slowly by appropriate treatment. The 
time necessary to bring it about depends upon the intensity 
of the process, the individual conditions, which are difficult 
to lay down, and finally upon the treatment followed. 
The latter is very long, with the exception of the very light 
cases where the inflammation is superficial and of slight 
density. When fibrous transformation begins, some months 
are required to arrive at a complete result. 

Hard Infiltration of the First Degree. — When the 
parvicellular infiltration begins to undergo fibrous trans- 
formation, there is forming, little by little in the midst of 
inflammatory zones, a sort of hard nucleus, masked by 
catarrhal swelling in the neighboring parts. When this 
swelling disappears under the influence of appropriate 
treatment, we see the hard nucleus appear, which had re- 
mained hidden up to this time. Such forms constitute 
a transition between the soft infiltration and the hard 
ones. 

Hard infiltration of the first degree comprises glandular 
forms and dry forms. 

Glandular Form. — The mucous membrane is pale and 
has lost its normal striation in a more or less complete 
manner; these modifications are not uniformly distributed, 
but exist only at the points which are diseased. The epi- 
thelium desquamates in spots, takes on an irregular, dull 
aspect, becoming at times opaque and forming small gray- 
ish plaques. The folds of the mucous membrane become 
less numerous; we do not find more than two or three, and 
even they disappear almost completely upon such mem- 
branes which are normally not well supplied with folds. 
Their complete disappearance corresponds, however, to the 
second degree of infiltration. Littre 's glands are affected 
with simple mucous swelling and appear as little groups 
with their orifices slightly congested and prominent. They 
are thus met with united, like a series of small pin -pricks in 
the midst of a fibrous white plaque. The lacunce have 



URETHRAL ENDOSCOPY 125 

the dimensions of a pin's head and at times discharge a 
muco- purulent fluid. Cicatrices which appear in this form 
are but slightly visible. We find very small ones in the 
mucous membrane itself or surrounding- the glands and the 
lacunae. These latter disappear quite readily, while the 
cicatrices of the mucous membrane at times persist long* 
after the cure of all the other diseased regions has taken 
place. 

Course and Termination. — Cure does not take place 
with equal rapidity in the whole extent of the affected 
zones. Experience has clearly demonstrated that it always 
takes place, ceteris paribus, more rapidly upon the lower 
wall of the urethra than upon the upper. It would, there- 
fore, be upon the latter that we must look for the last 
traces of the disease. We see, following treatment, that 
the membrane reassumes its normal color, the effaced 
stria? reappear quickly as the infiltration is absorbed. The 
epithelium again becomes even and shiny, the grayish 
plaques disappear, the folds become more and more 
numerous, while the mucous membrane regains its elas- 
ticity. The glands recover their normal features because 
the infiltration has not been sufficient to bring about their 
destruction; finally the swollen lacuna? dilate, their orifices 
become crater -like, and then take on their usual aspect 
although they may remain surrounded by a reddish circle 
which, however, has no importance. 

Dry Form. — The diseased areas are pale and take on a 
uniformly yellowish gray aspect, as though mortified. 
The strice remain visible, while the epithelium shows 
marked desquamation and the folds of the mucous mem- 
brane are completely effaced. The glands of Lift re are 
invisible as well as the lacunae, their lesions remaining in 
the sub-mucousa; however, in the course of the disease, 
some of them may open on the "surface; they then present 
the lesions of simple inflammation. 

Course and Termination. — Under the influence of treat- 



126 CHRONIC URETHRITIS 

merit all the features slowly disappear, but with much less 
rapidity than in the glandular form. The uniform grayish 
color, especially, persists for along time, and the membrane 
does not take on its normal bright red aspect before the 
cure is complete. The epithelium, likewise, remains dull 
and lifeless for a long while and does not show its normal 
appearance until after complete disappearance of the sub- 
jacent infiltrations. Thus the epithelial characters, in 
intimate connection with the changes in the mucous mem- 
brane, offer the best sign of progress obtained by treat- 
ment, and a complete cure cannot be proclaimed until the 
surface of the mucous membrane has again become normal, 
quite smooth, moist, and shiny. 

As to the glands, their lesions escape for the most part 
the endoscopic examination; under the influence of dilata- 
tions the excretory ducts open slowty, and their orifices 
become visible in more and more considerable number; 
they are slightly swollen and reddish, permitting the escape 
of pathological products formed in the glands, then again 
slowly disappear after cure. At times the glands being 
covered over with a more resisting layer, the latter does 
not give way at once to dilatations; the products then 
accumulate, raise up this covering, and form small, trans- 
parent cysts which end in breaking upon the surface of the 
mucous membrane. The orifice thus produced has its 
swelling subside gradually just as in the first case. 

Finally, the cysts more deeply situated break in the 
midst of the mucosa, and their products are absorbed. 
Some of these cysts inaj 7 even persist after complete cure; 
they are then enveloped in a resistant, fibrous capsule; 
their presence is not of much importance. At the same 
time that these glandular lesions are going through their 
evolution, small superficial cicatrices may form in the sur- 
rounding parts, but not generally in their immediate 
neighborhood. On the contrary, these cicatrices immedi- 
ately surround the opening of the crypts. Just as in the 



URETHRAL ENDOSCOPY 127 

glandular form, when cure is completed, small white cica- 
trices may show themselves on the surface of the mem- 
brane, but their appearance is not at all constant. 

Clinical Details. — From a clinical standpoint a few 
considerations are not lacking- in interest. These forms of 
infiltration of the first degree generally show themselves 
two or three months after the beginning of infection. 
They may then remain stationary for months without 
undergoing any modification, on condition, be it under- 
stood, that no new infection occurs, that the patient com- 
mits no excesses of any kind, and that he carries out no 
energetic local treatment. At the expiration of a variable 
time, generally about a year, a sort of spontaneous cicatri- 
zation occurs, especially in the glandular forms, while the 
dry forms seem more resistant. At the same time that 
these superficial cicatrices show themselves, the caliber of 
the urethra may become slightly narrowed, especially when 
the infiltrations are located at the points which are already 
normally the most narrow in the canal. These strictures, 
which in subjects whose bladders are devoid of energy, 
may produce disturbances of miction, are cured with great 
rapidity; they are thus distinguished at first glance from 
true strictures of the urethra. 

These forms are accompanied by a more or less abun- 
dant suppuration according to individual conditions which 
are difficult to define; suppuration, however, is quite often 
lacking in the dry form. 

Hard Infiltration of the Second Degree. — Under this 
heading are included all instances of chronic urethritis in 
which infiltration has been sufficiently dense to cause an 
appreciable restriction of the caliber of the urethra, with- 
out, however, this stricture proving an obstacle to the pas- 
sage of a number 23 endoscopic tube, the smallest we can 
employ. 

This division is evidently arbitrary; we must, how- 
ever, remark in this connection that urethra? which have 



128 CHRONIC URETHRITIS 

become too narrowed to admit the number 23 tube, 
at the first examination, or after oue or two dilata- 
tions, are no longer affected simply with chronic urethritis. 
This urethritis is then complicated by a stricture in the 
true surgical sense of the word, and the diagnosis, the 
prognosis, and the treatment are decidedly modified. 

The class of hard in filtration of the second degree in- 
cludes the great majority of cases of simple chronic urethri- 
tis which come to us for treatment. We naturally do not 
here find lesions other than those found in the cases pre- 
viously described; but these lesions are deeper, more ex- 
tensive, and more severe. 

Glandular Form. — The membrane is pale and anemic by 
reason of the compression exerted by the infiltration upon 
the vessels, and this pallor is especially well marked in vas- 
cular mucous membranes, while it is distinguished less well 
from the normal color in anemic membranes. We may 
notice here and there red outlines which are altogether 
wanting in the dry form. The striation has disappeared 
and is not found again, except upon the borders of the 
lesions, where there always exists a less -pronounced infil- 
tration than in the center. 

The epithelium may present a great variety of lesions. 
Less affected in the peripheral zones it will be slightly des- 
quamating, or will present a simple, glassy swelling. On 
the other hand, in the center of the foci, where the lesions 
are more severe, we find grayish scales, more or less exten- 
sive and thickened. When the lesions are superficial, the 
desquamation is lighter and the surface of the membrane 
takes on an irregular aspect. 

The folds disappear completely at the moment the infil- 
tration is sufficiently dense; the thickened and hard mem- 
brane now forms one single mass with the sub -mucous 
tissue; it does not fall together, or fold in upon itself 
when the endoscope is withdrawn, but forms a sort of rigid 
tube which remains open. It recovers its mobility as the 



URETHRAL ENDOSCOPY • 129 

infiltration is absorbed; at the same time it becomes more 
supple, and its surface begins to fold slightly at certain 
places, while large, prominent, hard nodules still remain at 
such points where improvement is less evident. 

Littre's glands, whose excretory ducts are surrounded 
by a zone of connective hyperplasia, appear hypertrophied. 
They are united in groups and present all the forms of 
lesions of chronic inflammation which we have described. 

The lacuna are perceived at the first glance; they are 
surrounded by thick nodules of infiltration ; the orifices are 
prominent, with borders swollen and glassy. The tissue 
proper of the mucous membrane is itself invaded by infiltra- 
tion. At their periphery the areas present zones of soft 
infiltration, or of soft infiltration of the first degree; the 
severest lesions are at their center; here are also encoun- 
tered small plaques of granular tissue, of which we have 
already spoken. These plaques are grayish, yellowish, of 
lardaceous appearance, almost completely deprived of gland- 
ular groups; they do not measure more than one or two 
centimeters in extent, are readily torn by the simple pas- 
sage of the endoscope, and are surrounded by smooth, dry 
masses of deep infiltration in which are found swollen 
glands and lacuna?. Cicatricial tissue is rare; it belongs 
to the stage of regression. 

Dry Form. — The dry form belonging to the second 
degree is much more frequent than the corresponding 
glandular form. We do not encounter granular areas such 
as we have just described. The infiltration is not localized 
in irregular foci, but it spreads out more uniformly over a 
certain area o£ surface of the mucous membrane; at times, 
also, over the whole length of the anterior urethra. The 
introduction of the urethroscope frequently permits one to 
note a peculiar resistance, and one which is characteristic 
to an experienced hand. This resistance is uniform and 
does not result in the series of sudden jumps produced by 
the irregular nodules found in the glandular form. To 



130 CHRONIC URETHRITIS 

make out the peculiar features of this form, one should 
select a case which has not yet been subjected to dilatation. 
The mucous membrane then seems uniformly yellowish 
gray, of cadaveric aspect; the strice, still visible in the 
peripheral zones, have entirely disappeared at the points 
where infiltration is deep. The epithelium is dry, dull, 
without brilliancy; it undergoes a very fine desquamation 
and seems as though covered with a grayish dust which, 
however, urination or the injection of cocaine removes. 
The folds of the membrane have disappeared. The glands 
of Littre are invisible or appear here and there isolated 
and without areas of infiltration at the periphery. The 
lacunae which one sees are small, scarcely surrounded by a 
slight reddish circle, and present neither prominent orifices 
nor nodules of perilacunar infiltration as in the preceding 
form . 

In this dry form the infiltration has especially invaded 
the deeper parts of the mucous membrane; but the latter 
seems to have preserved its elasticity better than in the 
glandular form, and but rarely forms a rigid canal. It 
resists less the passage of the urethroscope, and returns to 
its previous condition more readily when the instrument is 
withdrawn, so that the central figure, while not closing 
completely, does not remain entirely open, and forms a sort 
of oval. 

The infiltration, which is more regular than in the 
glandular form is, however, not entirely uniform; it has 
invaded more particularly certain points, which successively 
fall into the distal opening of the endoscope. We en- 
counter neither granular foci nor cicatrices. These latter 
only appear as the cure is effected. 

Course and Termination. — Cure in the infiltrations of 
this degree is never obtained without being interrupted by 
recurrences. It is always extremely slow, and the mani- 
festations, which are produced as improvement goes on, 
present infinite variations. 



URETHRAL ENDOSCOPY 131 

In the glandular form we see the normal color and the 
stria reappear slowly as the infiltration tissue is absorbed; 
the contour of the diseased zones becomes less and less 
clearly marked, and the central focus breaks up, as it were, 
into small nodules of which the smallest progressively melt 
down, while the larger resist and end by dividing up into 
indifferent cicatrices. The epithelium at the same time 
slowly regains its normal features, but remains, however, 
for a long time irregular and opaque near the persistent 
nodules and the cicatrices. 

At the same time that the infiltration diminishes in 
density, the folds of the membrane are seen to reappear. 
These folds are very coarse at the beginning; they remain 
in this state for a long while, at times indefinitely, when 
large cicatrices are formed. 

The Littre glands and the lacunae begin by opening 
widely under the influence of dilatation; their orifices be- 
come ci-ater-like, then disappear gradually by becoming in- 
visible, either by reason of complete cure, or through 
atrophy and destruction of the gland. At other times, 
on the contrary, the orifices remain visible for a long time 
surrounded by a red circle. Finally, small annular cica- 
trices may form around the lacunae, or about the glandular 
groups, then disappear by a continuation of the process of 
resorption . 

These phenomena which we have described at greater 
length in the appropriate chapter, are observed by prefer- 
ence, as far as the glands are concerned, in the lower wall 
of the canal, and in regard of the lacunas on the upper wall. 
After complete cure, when only a few indifferent cicatrices 
remain, we also see a certain number of glands or lacunae 
persist; the normal aspect of their orifices, the absence of 
infiltration in their surroundings, and especially the char- 
acter of the epithelium covering them, indicate that they 
are completely cured. We find them, especially in this 
state, on the surface of dead cicatrices. As to the mucous 



132 CHRONIC URETHRITIS 

membrane itself, the process of cure varies very much 
according to the extent of the infiltrations which have 
invaded it. If we have to do with superficial lesions, 
treatment by dilatation may provoke complete absorption 
without any cicatricial formation. These same infiltra- 
tions left to themselves tend, however, to undergo 
little by little their transformation into fibrous tissue. The 
reticulated cicatrices, which are gray and brilliant, with 
little vascular arborizations, and scattered with glands and 
lacunae, soon appear upon the surface of the mucosa, or we 
see a net- work of varying dimension, with thick trabecule 
at times raised, and even forming a prominent nodule in 
the lumen of the canal. This form of a fibrous plexus is 
also observed during spontaneous cicatrization of the gran- 
ulation tissue. The meshes are the more voluminous the 
deeper the infiltration; then they retract according as the 
parvicellular infiltration is absorbed, and it is transformed 
into white cicatrices. As to the large nodular masses 
which at times take in half the circumference of the 
urethra, they do not disappear as quickly because they are 
composed of encapsulated glandular masses in fibrous 
tissue, which resist treatment longer. 

All these processes of cicatrization are enormously ac- 
celerated under the influence of a proper course of treat- 
ment with dilators. The superficial infiltrations are rapidly 
absorbed, and we see the folds of the membrane reappear 
again. We even see the process of resorption going on 
in the deeper infiltrations, around the traumatisms and 
slight tears due to the dilatation. The cicatricial tissue in 
process of formation can thus become absorbed; but the 
large nodules developed about the glands resist the action 
of the dilators for a longer time. 

In the dry form, the process of cure is analogous, but 
its course is always very slow. As the infiltration tissue is 
absorbed, the mucous membrane is seen to take on a 
brighter color and to gradually lose its characteristic yel- 



URETHRAL ENDOSCOPY 133 

lowish gray appearance; at the same time faintly marked 
sir ice reappear. The epithelium, which is irregular and 
dull, retains this feature for a long time, and does not take 
on again its glistening and clear aspect until complete cure 
is established; the mucous membrane loses this stiffness, 
or rather this absence of elasticity which caused an ob- 
stacle to the introduction of the endoscope. 

As to the glands and lacunce, their fate varies some- 
what according to the deeper or more superficial inflamma- 
tion in the tissue of the mucosa. The most superficial, 
under the influence of dilatations, open upon the surface 
of the mucous membrane, and their subsequent course 
is run as in the glandular form; the peripheric engorge- 
ment is little by little absorbed, and cure takes place. 
Cysts more deeply situated rupture within the mucous 
membrane and thus disappear. We see the white nodules 
with which the canal was strewn disappear by degrees. A 
few, however, remain. These may become completely en- 
capsulated within the cicatricial tissue and become harm- 
less; others should be destroyed by caustics or electrolysis. 

The cicatricial tissue is only seen in the dry form during 
the period of regression. We see small cicatrices appear 
about the glandular orifices; others form in the depth of 
the mucosa by fibrous retraction of the follicles. During 
the course of treatment acute recurrences are, so to speak, 
sure to come in both forms, but especially in the dry. 

Cure is secured only by perseverance. When it is com- 
plete, the older foci should again present the following fea- 
tures: The mucous membrane should again have assumed 
an almost normal color, and the epithelium, aside from a 
few plaques which have become indelible, should be 
smooth, moist, and transparent; the striae should have 
formed again, and the mucous membrane should fold upon 
itself almost as though it had again taken on its primitive 
elasticity. The lacunae and the glands remaining visible 
should have a normal, not projecting, orifice, presenting no 



134 CHRONIC URETHRITIS 

inflammatory features. It may happen that some peri- 
glandular infiltrations still persist, but they should be 
superficial and covered over with normal epithelium. 
The cicatrices, if any exist, should be superficial, smooth, 
and covered with a healthy epithelium. 

Clinical Details. — The hard infiltrations of the second 
degree, which are also accompanied by a slight diminution 
in the caliber of the urethra, are only observed two or 
three months after infection. At times their forma- 
tion is not preceded by a truly acute period, and we are 
quite astonished to find them in patients who, without 
having had a true clap, have complamed for some time 
of itchiness within the canal, accompanied by a slight 
moisture at the meatus. Generally these infiltrations are 
formed slowly after an acute urethritis apparently cured, 
and give rise, subsequently, to so-called new attacks of 
urethritis. Once formed, these infiltrations are no longer 
spontaneously absorbed. They may extend very slowly at 
the same time as there appears at their center a gradual 
process of cicatrization which we have described and which 
continues for years. They may also pass into the third 
degree and thus constitute strictures properly so called. 

The cure is obtained under the influence of appropriate 
treatment, but this treatment will be necessarily verj r slow, 
especially in the dry form in which a year or more may be 
required. 

Hard Infiltrations of the Third Degree — Strictures 
of the Urethra. — We have arranged in this group all 
the cases in which the infiltration is so dense that the 
urethroscopic tube number 23 can not pass into the canal. 
This division may appear entirely arbitrary; indeed it is so 
from a purely scientific point of view. The infiltrations 
which belong to this group are not to be differentiated 
from those we have already seen, excepting by their greater 
density; but they have a practical importance which is 
quite considerable. 



URETHRAL ENDOSCOPY 135 

Most practitioners, indeed, treat strictures of the 
urethra in an incomplete manner, once they have reached 
a caliber which seems to them sufficient — and number 23 
Ch. is here very often a high number — they abandon the 
stricture to itself, and wait patiently for the early recur- 
rence which is bound to follow. 

Now it is precisely at this moment that the true treat- 
ment of the affection begins, because it is only now we 
can take exact account of the state of the canal and follow, 
pace by pace, the progress of cure until the latter is com- 
plete and definite. 

Stricture of the canal does not differ in any way from 
an an atom a- pathologic standpoint from the infiltration 
which we have described in the preceding paragraphs; it is- 
simply a more advanced degree of the same lesion, and is 
characterized by the presence of a more dense infiltration. 
We must then a priori admit that the process of cure will 
pass through the same phases, with a slower course, un- 
doubtedly, but terminating finally with the same result, 
viz: resorption, as complete as possible, of the infiltration 
tissue; integral transformation of all that which can no 
longer be resorbed into indifferent cicatricial tissue. The 
latter is characterized by the absence of all inflammatory 
element; it has become incapable of giving rise to a recur- 
rence; that is to say to a new access of inflammation. At 
this moment, only, the cure will be complete and definite. 

The formation of an infiltration, which is accompanied 
by stricture of the canal, is not characterized by any par- 
ticular phenomenon. It always requires at least several 
months, at times years; it is made active by frequent 
recurrences of urethritis. We see at times, even in the 
course of treatment, that the infiltration extends in spite 
of all efforts. We are thus forced to be silent lookers-on 
during the formation of a stricture which we can begin to 
combat only at a later date. If we have before us a nar- 
rowing of the canal, we must begin by making dilatation 



136 CHRONIC URETHRITIS 

according to the ordinary rules until we can pass a number 
23. We must then examine, with the urethroscope, by 
employing a tube well smeared with glycerin, which we 
slowly introduce while holding the penis with the left hand. 
If it does not pass, we attempt to incline the tube from 
one to the other side, so as to pass alongside of large cal- 
lous masses situated at times laterally; we should use no 
force, so as to avoid hemorrhage, which might make the 
•examination impossible, or at least compel us to put it off 
for from fifteen to twenty days. 

The anterior urethra may be infiltrated to the bulb, and 
we find this infiltration irregularly distributed. It is much 
more intense in certain points, which form the strictures. 
These are located generally in the middle portion of the 
anterior urethra, or frequently, also, in the region of the 
bulb, and especially immediately behind the latter at 
the entrance of the membranous region. The strictures 
which are situated at this point readily set up marked 
troubles of micturition. This peculiarity is due to their 
situation and also to the fact that the muscular fibres of 
€arcassoune's aponeurosis are invaded by the sclerogenic 
process. These strictures also form the chief obstacle to 
catheterism, and are for this reason the best known by 
surgeons. They are rarely encountered at the meatus. 
Finally, it is exceptional to find a canal, healthy in the 
greater part of its extent, to show at a single point an 
isolated stricture. 

The stricture itself is formed of large masses of dense 
and compact connective tissue, in which the vessels are 
compressed and the circulation very sluggish. The mucous 
membrane also is colorless, whitish gray, or of cartilaginous 
aspect, covered with a thick epithelium (pachydermia). It 
presents no longer either folds or strice, excepting in the 
peripheric zones of lesions less advanced, and forms a sort 
of rigid canal whose central figure remains open. The 
caliber of the canal being diminished at the level of the 



URETHRAL ENDOSCOPY 137 

stricture, the endoscopic tube is violently repelled during 
the examination of the canal, and the masses of infiltration 
suddenly pass before the eyes. The preceding dilatations 
have always produced a tear which is seen in the form of 
an elongated fissure, at least in the neighborhood of the 
stricture. In the tissue of the stricture itself the tear may 
have been sub -epithelial, and not apparent at the surface at 
all. The glands and lacunce are generally not visible at this 
period; they are scarcely to be encountered except in 
the parts relatively less affected, situated between the 
largest foci. But it happens occasionally, however, that 
diseased groups of glands are seen even in the midst of the 
fibrous masses of the stricture. 

The dry form is scarcely to be distinguished from the 
glandular. The masses of infiltration themselves are 
irregularly distributed; to recognize distinctly their ap- 
pearance, extent, and thickness, we must be able to employ 
a number 25 tube, and draw it out slowly, stopping at the 
moment when it passes through the strictured points, 
where it is opposed by the large and projecting nodules. 
We will see in this way that the infiltrated masses never 
occupy the whole circumference of the canal. Even in the 
most pronounced strictures they scarcely extend beyond a 
third or a half of this circumference. 

Course and Termination. — Strictures of the urethra can, 
up to a certain point, become spontaneous^ cured. This 
spontaneous cure does not extend to a restitutio ad integ- 
rum, but such has been capable of demonstration in patients 
who have never undergone an}* local treatment. It would 
seem then that the chronic inflammatory process becomes 
arrested, and that the lesion no longer spreads either on 
the surface or down into the tissues. The infiltration tis- 
sue is absorbed at the periphery, while in the center it is 
transformed into cicatricial tissue. If one has an oppor- 
tunity to examine one of these cases it is seen that the 
lesion is directlv continuous with the healthv tissue; that 



138 CHRONIC URETHRITIS 

the stricture itself, which has but a minimal extent, and 
scarcely admits the number 23 tube, is distinguished from 
the normal mucous membrane, because its pale rose, smooth 
surface, without folds, is traversed by deep cicatrices having 
at times a width of 0.005; that it has a fibrillary appear- 
ance, but does not enclose either diseased glands or rem- 
nants of normal mucous membrane. When strictures are 
subjected to an appropriate treatment the process gradually 
retrocedes. The normal color of the membrane returns 
only after complete cure. We first see disappear the 
red spots of the glandular form, but the grayish pachy- 
dermic appearance persists for a very long time, and dis- 
appears only with the progress of resorption. Even after 
cure, old strictures are always distinguished by a pale 
color at points where cicatrices persist. It is also rare to 
see a complete return of the normal striation, except in 
the peripheral zones. The pachydermic epithelium of the 
glandular form slowly desquamates, and this desquama- 
tion becomes more and more fine and delicate, so that we 
see the phases described in the preceding forms slowly 
gone through again. In the dry forms the epithelium 
keeps its dusty aspect for a long time before giving way to 
a smooth and transparent coating. 

However it almost never takes on again its wholly 
normal features at the site of a cured stricture, and often 
after years it has preserved a rugose aspect, which permits 
of its recognition. As to the mucous membrane itself, it 
is rare to observe a reappearance of the thin, pliant folds 
which it normally possessed; according as the resorption is 
produced, these folds appear in the peripheric zones, then 
very slowly and gradually show themselves at the point of 
stricture; but they are coarse and thickened in the glandu- 
lar form, finer in the dry form, without ever presenting 
anew an entirely normal aspect. At the same time we see 
these large foci of infiltration, which are quite visible in 
the period of their full development, diminish little by 



URETHRAL ENDOSCOPY 139 

little iii volume, become less and less thick, and no longer 
project so forcibly into the endoscopic field; the canal 
then becomes freer, although its normal elasticity does not 
reappear so quickly. Soon cicatrices appear, at first large 
and numerous, forming meshes which encircle the urethra, 
then they diminish slowly in volume, become fragmented, 
and disappear partially by resorption; but a few 
always persist under the form of small white bands sur- 
rounding the large follicular areas. Alongside of these 
cicatrices others are found which are formed by the lon- 
gitudinal tears which dilatation produces; these are broader 
and deeper, not having the fibrillary aspect of the others. 
They cut the stricture directly at the point where the most 
resistant masses exist, and one can see that it is in their 
neighborhood that the process of resorption is the best 
marked, because it is there that we see the first cicatrices 
appear, and the mucous membrane first take on again 
its characteristic folds. Finally the glands and lacunce, 
which are scarcely seen in the midst of the fibrous masses 
of the stricture, reappear gradually and pass on to cure, in 
going through the various phases described in the para- 
graph dealing with the smaller infiltrations. 

The time accorded to treatment of strictures should 
be an extremely long one. We cannot abandon them 
before the canal has become entirely free; the mucous 
membrane should have recovered its normal color, 
the epithelium should no longer present plaques of 
desquamation, it should be uniformly brilliant, the 
glands should no longer be surrounded by areas of infil- 
tration, the cicatrices should no longer project nor present 
a reticulate appearance; finally, the canal should fall into 
folds in an almost normal manner. If follicular areas or 
infiltration nodules still persist, it will be well to suspend 
treatment for some months, to take it up again later. 
When a recurrence has taken place it will be readily no- 
ticed bv the diminution in caliber of the canal. We also 



140 CHRONIC URETHRITIS 

note the resistance experienced in introducing the usual - 
sized urethroscope, and especially the difficulties which dila- 
tation will present and the paiu it will produce. The 
mucous membrane will show reddened plaques scattered 
over with pachydermic points; the infiltrations, which had 
diminished, will again become prominent, especially about 
the glands and cicatrices. But under the influence of an 
appropriate treatment these recurrences readily give way. 
We must, however, especially if they are frequent, keep the 
case under observation for years. There are few strictures 
which do not show some recurrences; these occur in sub- 
jects of some diathesis, such as the tuberculous, etc. We 
should then bring into our treatment as much patience and 
perseverance as possible, if indeed the patient is not lost 
sight of before the cure is complete. We must never give 
up the treatment of a stricture before such cure has been 
obtained, else the recurrence is assured. 

We have seen that even with prolonged treatment it is 
impossible to give to the mucous membrane all its normal 
features again, but we are in a position to exact at least the 
total and definite disappearance of chronic inflammatory 
lesions capable of being the point of departure for new in- 
flammatory outbreaks and, without doubt, of a reinfection. 

IV. Endoscopy of the Posterior Urethra. — The 
posterior urethra (membranous and prostatic portion) is 
clearly defined and differentiated from the anterior part of 
the canal. Its structure and its physiologic role are both 
different. We have seen that the clinical symptoms of 
urethritis change entirely once it is attacked. The urethro- 
scope study is quite different. Therefore we have thought 
best to give to this study our special consideration. The 
urethroscope examination of the posterior urethra is made 
much more rarely than the examination of the anterior 
portion of the canal, because chronic gonorrhea which 
becomes localized here much less often than we are apt to 
think, has a tendency to invade the annexed glands rather 



URETHRAL ENDOSCOPY 141 

than the surface of the mucous membrane itself. Further- 
more, as this examination is, as a general rule, quite 
disagreeable to the patient, we must guard against 
unnecessarily having recourse to it, and refrain from it 
absolutely if the affection still presents some features 
of the acute stage. An almost absolute contra-indica- 
tion is found in tuberculosis and prostatic hypertrophy. 
When we wish to employ the urethroscope for examina- 
tion of this region, we must begin with a quite com- 
plete anesthesia. We should use from one -half to one 
gram of a ten per cent cocaine solution. We could even 
employ stronger solutions, in case of necessity going up to 
forty per cent. The effect is obtained only after some 
twelve minutes. 

Endoscopic tube number 23 is insufficient for a de- 
tailed examination of the region; it can serve only as a 
means for a general observation, and it is indispensable to 
begin with it. Later on, when the sensitiveness of the 
canal becomes somewhat blunted, we may take numbers 25 
and 27, which will give more precise details. 

The patient should lie comfortably stretched out upon 
an examination table sufficiently raised for the ease of the 
operator, the legs bent and separated, the pelvis slightly 
raised. 

Oberlander has constructed a jointed obturator, per- 
mitting it on the one hand to bend at an elbow so as to 
give to the urethroscope, at the time of introduction, ap- 
proximately the form of a curved sound and, on the 
other hand, to be straightened out again when it is to be 
withdrawn from the urethroscopic tube (Fig 10). But 
we believe that this instrument is unnecessary, and we pre- 
fer to use the ordinary obturator. This is, however, a 
matter of personal preference. The method of catheteriza- 
tion with a straight instrument is, in general, not difficult. 
We begin by introducing the instrument into the anterior 
urethra until its point has reached the bottom of the bulbar 



142 CHRONIC URETHRITIS 

region and strikes against the perineal aponeurosis; the 
handle is then slowly lowered so as to slightly raise the 
point and direct it toward the opening of the membranous 
region. By means of a very slight pressure we then push 
the sound into the membranous urethra, and continue in 
this manner to cause its slow advance by lowering the 
handle at the same time, and thus straightening by degrees 
the curve of the canal. This manipulation, when well 
executed, aside from the slight pain which the passage of a 
bougie always causes in this region, provokes only a sensa- 
tion of tension by no means intolerable. We encounter 
difficulty only if the movement of depressing the handle is 
insufficient and if the point of the urethroscope catches in 
traversing the ridge of the verumontanum projecting upon 
the lower wall. 

Having reached the bladder, w r e withdraw the obturator. 
A preceding catheterization has emptied the organ, and small 
pledgets of cotton on holders are now sufficient to remove 
the remnants of urine. The urethroscope is now slowly 
withdrawn. When we thus come back into the canal, the 
funnel formed bj r the mucous membrane appears at once; 
this aspect is quite different from that which one observes 
as long as the instrument remains in the bladder; it is thus 
an easy matter for one to know his whereabouts. The ex- 
amination made in this manner is directed successively to 
the region situated behind the verumontanum and to the 
verumontanum itself in its whole extent. 

These manipulations are almost always accompanied by 
a slight hemorrhage, at least at the first examination; if 
these hemorrhages occur repeatedly afterward, they are 
indicative of superficial lesions (epithelial lesions, gran- 
ulations, papillomata, etc,). 

The diagnosis of the lesions one meets with in the pos- 
terior urethra, and especially in the region of the verumon- 
tanum, exacts a decided dexterity in the examination of 
this region. We may encounter not only lesions produced 



URETHRAL ENDOSCOPY 143 

by old gonorrheas, but also anatomical changes brought 
about by sexual excesses of all kinds. Generally the 
lesions found in this situation are due to a concurrence 
of these two factors. The existence of gonorrhoic lesions 
in the anterior portions of the canal — which should, 
by the way, have been already studied and cared for before 
going further back — will often come in to clear up the diag- 
nosis which might otherwise remain in doubt. Besides, 
the chronic lesions of the posterior urethra are only very 
rarely limited to the mucous surface. In the great ma- 
jority of instances they have invaded, at the same time, the 
genital glands (prostate, testicles, seminal vesicles, etc.). 
These are the complications which have for us the great- 
est importance; because the lesions of the mucous mem- 
brane, when they exist alone, get well, as a rule, quite 
rapidly. 

The Posterior Urethra in the Normal State. — The mucous 
membrane of the posterior urethra is distinguished by 
its extreme delicacy; it is of a brighter color than that 
of the anterior part, of slightly dull aspect, and forms 
small, very thin folds when the urethroscope is drawn out 
slowby. The verumontanum presents at points particular 
interest. Its dimensions, its aspect, and even its situation 
are far from being constant. In making a urethroscopic 
examination, w T e see it projecting from the inferior wall 
of the canal under the form of a rounded protuberance 
of the dimension of a lentil, and of a yellowish rose 
color. This aspect, as the tube is withdrawn, extends 
over a stretch of from one to one and a half centimeters; the 
projection becomes smaller and smaller, and then becomes 
wholly effaced. The dimensions of the verumontanum are 
generally in relation with the dimensions of the canal; in 
a weak individual, whose penis is but slightly developed, 
it is scarcely a centimeter in length, and the projection 
it makes into the urethroscope is only slightly marked. In a 
vigorous individual it is longer, and forms a projection 



144 CHRONIC URETHRITIS 

strongly marked, which cannot escape examination. To- 
ward the anterior extremity and on the sides of the veru- 
montanum are seen the orifices of the prostatic ducts. 
These are small punctiform cavities less marked than the 
orifices of the Morgagni lacuna?, and do often escape exami- 
nation. The orifices of "the ejaculatory canals are of much 
more considerable dimensions; however, it is difficult to 
perceive them; they are found upon either side of the 
verumontanum. The entrance to the prostatic utricle is 
more easily distinguished, and we can find it quite 
readily in employing a tube of appropriate dimensions. 

When, after this complete examination, we continue to 
slowly withdraw the urethroscope, we see the verumon- 
tanum stretched out upon the inferior wall in the form of a 
ridge, the latter at times reaches even to the region of the 
bulb. In the membraneous portion the mucosa is fine 
and very vascular. It appears, through the endoscope, of 
a bright red color forming radiating folds extremely delicate 
and numerous. 

At the moment when the urethroscope penetrates the 
region of the membranous sphincter, it is pushed upward 
by the tonic contraction of this muscle. This contraction 
compresses the vessels and gives to the mucous membrane 
a peculiar aspect; it seems anemic, dull, and withered. 
Then the canal enlarges to form the bulbar region. At 
this point we distinguish, at times, a slight elevation 
whose aspect recalls somewhat that of the verumontanum, 
but whose dimensions are much less. We see a few small 
orifices analogous to those of the prostatic ducts. This 
prominence seems to correspond to the origin of the ducts 
coming from the glands of Cooper. (Oberlander). 

Pathology of Posterior Urethritis .— Chronic posterior 
urethritis is, like the anterior, characterized by the forma- 
tion and evolution, in the midst of the mucous membrane, 
of an infiltration composed of embryonic cells which tend 
to become transformed into fibrous tissue. These infiltra- 



URETHRAL ENDOSCOPY 145 

tions are also divided into soft infiltrations and in those 
which are hard and fibrous. 

The soft infiltrations are frequent; they are found after 
acute urethritis, and have a marked tendency toward 
spontaneous cure when they are not accompanied by any 
prostatic or other complication . They are found localized 
sometimes at the verumontanum alone, and without any 
other lesions being discoverable through the whole extent 
of the urethra. In this case we must exclude gonorrhea 
and accuse other factors — masturbation, for example. 

The hard infiltrations succeed the soft ones, and they 
may invade the whole posterior urethra; but we especially 
find them in the membranous region, and in this case they 
follow the infiltration of the bulbar region. 

We shall presently see the modifications which the 
urethroscopic picture of the various elements of the urethral 
mucous membrane undergoes when it is invaded by chronic 
inflammation; we will then study, as we did in the anterior 
urethra, the various forms of chronic posterior urethritis. 

I. The color of the membrane is the first to suffer 
changes. When it is the seat of a soft infiltration, its 
color, normally blood-red, becomes a dull red, in some cases 
almost cyanotic; it also loses its luster. When cure has 
been effected, the membrane rapidly takes on again its 
polished aspect, and then gradually its normal color. 

When it is invaded by a hard infiltration, the mem- 
branous region takes on a grayish red color, even a slightly 
yellow one; its brilliant luster disappears to make room 
for a dull, dry aspect, without reflex. 

When the infiltration is in the prostatic region, the 
features are less distinct, the color remains rosy, scattered 
with bright red normal plaques. The verumontanum 
presents analogous features, but its anterior extremity 
seems flattened and does not project from the inferior wall 
of the canal. 

II. Epithelium in the posterior urethra is much more 



146 CHRONIC URETHRITIS 

delicate than the covering 1 of the anterior portion of the 
canal, and is composed of several superimposed layers, 
forming a transition between stratified cylindrical epithe- 
lium and the fiat epithelium of the bladder. In soft infil- 
tration this epithelium is simply swollen. In hard infiltra- 
tion it desquamates readily; the mucous membrane is at 
times also denuded over a very considerable extent, and it 
is to this complete desquamation that we must attribute 
the hemorrhages which are so readily produced during the 
introduction of the urethroscope. At other times, on the 
contrary, the membrane is indurated and covered with a 
finely granular epithelium analogous to that met with in 
the dry forms of anterior urethritis. Finally, the epithe- 
lium may become pachydermia, and the canal forms a 
tube of pearly white color. 

Here we encounter granulations very frequently, more 
pronounced even than those of the anterior urethra, 
which should be regarded as the origin of the papillomata 
which are so frequent in this region. When cure has taken 
place, these characters become gradually obliterated as the 
infiltration of the mucosa becomes absorbed. 

III. The folds of the mucous membrane are seen almost 
only in the membranous region; they become larger under 
the influence of a soft infiltration; and, on the contrary, they 
are no longer to be found when the mucous membrane has 
become indurated by reason of fibrous infiltration. The 
wall of the urethra, especially in the membranous region, 
is then smooth, for the nodular masses are not so prom- 
inent in the posterior as in the anterior region of the 
urethra. 

The folds return as cure is effected, and this takes place 
with considerable rapidity, for the treatment is much 
shorter than that called for by analogous lesions situated 
in the anterior urethra. 

IV. The Glands. — Littre's glands are few in number 
and but slightly developed. Their lesions are the same as 



URETHRAL ENDOSCOPY 147 

in the anterior urethra but much less well marked and 
without great pathological importance. The genital glands, 
on the contrary, are of great importance, and are the 
object of quite a special study. We mention them 
here only because the orifices of their excretory ducts 
open in the posterior urethra, and are there visible through 
the urethroscope. These orifices are inflamed and sur- 
rounded by a reddish zone. The largest among them is the 
orifice of the prostatic utricle; the orifices of the prostatic 
ducts are also generally seen; those of the ejaculatory 
ducts are more difficult to see because they are generally 
hidden by the swelling of the verumontanum. At times 
these orifices, instead of being simply inflamed, are 
choked up by fibrous infiltration; they are then dis- 
tinguished with greater difficultly and appear small and 
closed, surrounded by a slightly reddened areola. 

V. The Verumontanum constitutes the most important 
part of this region. When it is the seat of soft infiltration 
it swells, becomes dull red and cyanotic; its surface loses 
its smooth aspect, becomes, as it were, wrinkled, forming 
at times one or two deep folds. These characters disap- 
pear simultaneously when cure takes place. 

When the infiltration is hard, the verumontanum is 
flattened and of yellowish color; the surface is dull and 
without glare, as though dried out. At other times it is 
deformed by cicatrices; this is especially noticeable after 
old prostatitis. When the infiltration of the verumontanum 
spreads out also to the neighborhood, the cure is slow; 
but gradually the red color returns, to be followed by a 
bright red. At any rate it never again recovers its rounded 
and projecting appearance. 

Let us now study the various forms of chronic ureth- 
ritis that we may encounter in this situation. 

«. Soft Infiltration. — This form of urethritis is the 
slightest, and the one which is most readily cured. The 
mucous membrane in the membranous region becomes 



148 CHRONIC URETHRITIS 

dull red and loses its normal brilliancy; the folds which it 
forms are swollen. The glands of Littre, which are, by 
the way, few in number, have increased in size and pre- 
sent the features which we have described in the corres- 
ponding stage of anterior urethritis. 

The verumontanum is of equally dull red color and 
slightly swollen, but this swelling is quite difficult of recogni- 
tion because of the very variable dimensions of the organ 
itself in different individuals. All these features disappear, 
however, very rapidly when cure takes place. When it passes 
over into the hard form we encounter what may be called 
transition forms. The membranous region is then cyan- 
otic, the folds are no longer distinguishable, but the tur- 
gescent mucous membrane projects forcibly into the lumen 
of the urethroscopic tube. The epithelium is still intact 
and simply swollen. 

The verumontanum is clearly enlarged, of bluish red 
color, and more or less deeply plaited. The orifice of the 
prostatic utricle is gaping and inflamed, but the swelling 
of the verumontanum is at times so pronounced that this 
orifice, as well as those of the ejaculatory ducts, is lost in 
the tissue of the mucous membrane and remains hidden 
from view. When we can see these openings and those of 
the prostatic glands, they appear red, swollen, and sur- 
rounded by a prominent border. 

When cure takes place it begins in the membranous 
region, which takes on slowly its normal features, while 
the redness and swelling of the verumontanum persists for 
a longer time. When the surrounding mucous membrane 
has recovered its habitual appearance, the cure extends 
slowly to the vermontanum by finally losing all its morbid 
features within a few weeks. Acute recurrences are always 
possible in the course of treatment; they are almost in- 
evitable when the genital glands are affected. Therefore 
the treatment of these glands should precede the treatment 
for the urethritis, or at least they should be simultaneous. 



URETHRAL ENDOSCOPY 149 

This form of chronic posterior urethritis causes the same 
symptoms as vesical catarrh; it is especially important be- 
cause it is frequently the origin of nervous troubles. It 
appears at times a few weeks after the onset of the disease; 
it may also appear much later, when severe lesions exist in 
the anterior portion of the canal, constituting a complica- 
tion of these lesions. 

b. Hard Infiltrations. — The forms which result from 
the fibrous transformation of the infiltration are much less 
frequent in the posterior urethra than in the anterior part 
of the canal. This difference arises especially from the 
absence of conditions which favor the passage into the 
chronic state, and notably from the lack of Littre glands 
and of lacuna?. Here we do not find the glandular forms 
of anterior urethritis. All the forms resemble the dry 
forms. 

First Degree. — The mucous surface of the membranous 
portion seems dried out, as though it had lost its polish 
and brilliancy, is of grayish rose color, or even grayish 
yellow. The epithelium is desquamating. These characters 
are found in the prostatic region, but they are less pro- 
nounced, and we even see in spots the normal color of the 
membrane. The verumontanum is flattened, pale and, as 
it were, withered; the openings of the glandular ducts are 
small, slightly reddened, surrounded by an areola and, at 
times, emitting a discharge of viscid fluid. 

Second Degree. — In this form as well as in the form of 
the third degree, we must first dilate the canal before being 
able to introduce into it a number 25 urethroscope. This 
preliminary dilatation is, at times, of considerable dura- 
tion. When we then proceed with the examination, we 
find numerous flattened cicatrices which are pale, dry, and 
quite analogous to those we find in the anterior follicular 
urethritis. These cicatrices exist in the membranous 
region as well as in the prostatic region, where they invade 
even the verumontanum and go so far as the vesical orifice. 



150 CHRONIC URETHRITIS 

They are, at times, much developed without, however, reach- 
ing the dimensions of the fibrous masses which form the 
strictures of the anterior region. They are generally 
found to be already in the atrophic state, so that we do not 
find them projecting into the lumen of the urethroscope, 
nor presenting the reticulate appearance and the follicular 
foci of the anterior strictures. 

At times, however, the posterior strictures are greatly 
developed and form, by the rigidity of their wall, even 
when they have already been well dilated, an almost abso- 
lute obstacle to the entrance of the urethroscope. If, how- 
ever, we succeed in passing it we find all the character- 
istics of large strictures of the anterior part. The endo- 
scope traverses a rigid tube of rosy yellow or pearly white 
color. After repeated dilatations we find, later on, a 
cicatrix generally situated upon the inferior wall, having a 
dry surface and a star-like appearance. The neighboring 
mucous membrane seems dried out and faded. 

At times we find difficulty in dilating the canal. It is 
then that the urethral cicatrices extend into the periureth- 
ral muscles and the neighboring aponeuroses. However, 
even the strictures of this kind do not long resist treat- 
ment. The cure of forms showing hard infiltration fol- 
lows a course identical with that wmich we have described 
for the forms of anterior urethritis of the first degree, the 
color and the normal folds reappear at the same time that 
the membrane again takes on a brighter appearance. The 
cure is generally rapid; it lags at times a little in the 
region of the verumontanum, especially when the latter is 
decidedly infiltrated. But once affected, it never again 
takes on its normal appearance. These strictures, how- 
ever, are not too rebellious to treatment, and are cured 
by absorption of the soft elements included in the fibrous 
masses; during the course of treatment recurrences take 
place readily, especially after excesses of all kinds. 

Clinical Details. — These hard infiltrations are formed 



URETHRAL ENDOSCOPY 151 

only, as a rule, after several years; they are always accom- 
panied by very marked symptoms of irritation or of vesical 
weakness, of nervous and sexual troubles, impotence, 
pollutions, spermatorrhea, etc. 

V. Appendix — Papillomatous Urethritis. — The 
papillomata that we find in the canal of the urethra do 
not necessarily follow a chronic urethritis, although this 
is usually the case. We see them, however, at times 
coming* on in individuals who have never been affected 
with gonorrhea. 

These papillomata are entirely similar to those which 
form upon the prepuce; they arise from an excessive pro- 
liferation of the mucosa at points where its papillae be- 
come exposed after desquamation of the epithelium. In 
the most benign instances they appear at the period of soft 
infiltration or at the beginning of fibrous transformation; 
they are then very small, remain isolated, and protrude 
into the distal opening of the endoscope. It is often only 
necessary to pass this instrument to cause their disorgan- 
ization and atrophy. They also disappear spontaneously 
at the end of a certain time. They may be encountered in 
every portion of the canal. There still exists a form of 
papilloma graver and more persistent. This is the larger 
polypus which, differing from the former, may obstruct 
the canal. It is often united in masses covered with a 
thick epithelium, and met with most often in the middle 
of the spongy portion. We find this formation in small 
numbers also behind the glans, in the bulbar region, and 
surrounding the verumontanum. Oberlander has seen 
them in one case to spread through the whole length of 
the urethra, and even invade the bladder. 

The polypi may become necrotic and disappear spon- 
taneously; but the production of these neoplasms does not 
cease, and is only ended by the cure of the lesion which 
gives it birth; for they develop, in general, upon the 
surface of hard, extremely resistant infiltrations, in which 



152 CHRONIC URETHRITIS 

we find granular and periglandular areas, and reticulate 
cicatrices forming veritable strictures. The existence of 
urethral papillomata is often not manifested bj r any 
symptom ; at times there exists only a slight mucous 
secretion. Generally they are discovered by chance. At 
other times, on the contrary, they occasion intolerable 
itching, or else they make their presence known by a 
violent hemorrhage -which comes on spontaneously. 

These neoplasms are not resistant, and the best method 
of removing them consists in scraping the surface of the 
urethral mucous membrane by means of the blunt ex- 
tremity of the endoscopic tube. They ma} r also be removed 
by the curette, and the surface of implantation may be 
cauterized. The most important point, however, is the 
treatment of the lesion which has occasioned them. 



PART THIRD 

TREATMENT 

There exists no disease whose treatment is, in general, 
so badly understood, and so insufficient as that of chronic 
urethritis. We have shown that this insufficiency of 
therapy results especially from the fact that diagnosis is 
not made in a sufficiently precise and complete manner. 

Therefore, having dealt in detail with the various points 
of diagnosis, we §hall not stop at the enumeration of all 
the methods of treatment which have been successively 
advocated only to again fall into disuse and become for- 
gotten. We shall confine ourselves to presenting some 
indications for the methods most generally employed to- 
day. We shall present, at the same time, the treatment by 
means of Oberlanders dilators as they are employed by us. 



(153) 



CHAPTER IX 

GENERAL TREATMENT 

Regimen. — Regimen is of the first importance. We may 
say that the best directed treatment would surely fail in a 
patient given over to excesses of all kinds and who would 
refuse to be restricted by a sufficiently vigorous regimen. 
This should, however, not be excessively severe. It is 
useless to prescribe complete abstention from all irritating 
alimentation, from alcoholic drinks, from physical and 
moral fatigues, and from all sexual excitement,- as we do 
in acute gonorrhea. We do not believe, once the disease 
has passed into the chronic period, that the use of beer or 
of wine, taken in moderate quantity, and especially at 
meal -time, can have an injurious influence on the urethral 
mucous membrane. We forbid absolutely the use of 
liquors. Without condemning the patient to complete 
repose, we forbid physical fatigues as well as horseback 
riding and the bicycle, at least so far as this interdiction 
is compatible with the patient's occupation and social 
exigencies. 

It is impossible to formulate a fixed rule to cover these 
different points. Any given patient, in whom the least 
liberty in regimen calls forth an acute recurrence or an 
aggravation of symptoms should submit to a strict regimen. 
In others, On the contrary, the urethritis will be of a more 
torpid form and will scarcely react, no matter what may 
be the causes of irritation which could influence it. It 
rests, then, with the physician to discriminate as to these 
points according to the constitution of the patient; his 
habits, the moderation with which he would follow out any 

(154) 



GENERAL TREATMENT 155 

liberties granted him ; or, on the contrary, the abuse he 
might make of am latitude allowed. 

As to the sexual act, it will evidently be better to sup- 
press it in an absolute manner in order to withhold the 
patient from all danger of renewed contagion. This point 
is the more important, since the urethral mucous mem- 
brane, still diseased, offers a soil already prepared for 
all infectious processes, whether these be of gonorrhoic 
nature or simply the products of indifferent pyogenic 
micro-organisms. 

[When the acute stage of gonorrhea has subsided and 
the process has lost its activity, either by the entire disap- 
pearance of the gonococci or by their latency in the deeper 
structures, the mucosa of the urethra is left in a very vul- 
nerable condition. Janet aptly divided the stages of urethri- 
tis as follows: First, the stage of the invasion of gono- 
cocci; second, the anatomical and trophical lesions caused by 
the gonococci; and third, the secondary infections. Any of 
these three stages can be ascertained by the microscope, and 
each of them should be treated differently. The discharge 
in chronic gonorrhea does not always contain gonococci. 

In a minority of cases we will find the discharge to con- 
tain streptococci only, with the addition of various diplo- 
cocci (Fig. 4, B) . These, however, differ in their size, stain- 
ing, and decolorization qualities from the true gonococci. 
These micro-organisms, while non- pathogenic for a healthy 
urethra, which they inhabit with impunity, may assume 
violent properties in a urethra debilitated by the gonococci, 
or their toxins, or irritated by chemical, mechanical, or 
sexual influences. For instance, chronic constipation may 
cause the invasion of the bacterium coli into the urethra by 
way of the blood- and lymph -channels. Especially predis- 
posed and receptive to these violences will be the urethra 
of individuals with gout\- or scrofulous constitutions. 
This secondary infection causes a non -gonorrhoic bac- 
cilary discharge, and must be treated by antiseptic astrin- 



156 CHRONIC URETHRITIS 

gents (flushing with bichloride solution 1 in 20,000— 
1 in 10,000; or nitrate of silver 1 in 2,000— 1 in 1,000) . 

In some even much rarer instances the discharge of 
chronic urethritis will be devoid of all micro-organisms, 
containing only mucus and epithelium imbedded in a net- 
work of fibrin (Fig. 4, ilfand E., p. 51) In this case we speak 
only of a catarrhal aseptic discharge as a post-gonorrhoic 
manifestation. Here the simple astringents will effect a 
cure. If a mixed infection is present (gonococci and pus 
cocci), the anti-gonorrhoic remedies must first be applied 
and then the antiseptic astringents. Another, although 
rare, source of non-gonorrhoic discharge may have its 
cause in the presence of papular efflorescences of secondaiy 
syphilis in the urethra, or in intra-urethral chancres, or in 
some irregularly scattered glands whose excretory ducts 
open on the inner surface of the orificial lips (Diday), or in 
para- and periurethral ducts. In this latter instance with 
and without gonococci. It is therefore advisable to be on 
the lookout for such eventualities, especially as the para- 
and periurethral ducts may serve as secure hiding places 
for gonococci, causing reinfection of the urethra. They 
must be destroyed by the galvano -cautery.] 

Unfortunately, since treatment is often of long dura- 
tion, there is little chance that this interdiction be observed 
to the end. Besides noctural emissions, almost necessarily 
caused by this prolonged continence, have an equally bad 
effect when we make due allowance for the dangers of con- 
tagion. In some subjects, too, these nocturnal losses have 
a deplorable moral effect. Therefore it is better not to be 
absolute in the matter, and permit the patient to practice 
coitus with all possible moderation and, if it is possible, 
with the protection of a condom. 

Internal Medication.— Internal medicines have not 
sufficient power of themselves to bring about cure. Still 
they oftentimes form useful adjuvants. 

The balsams (copaiba, cubebs, santal oil, and turpen- 



GENERAL TREATMENT 157 

tiue) are not without influence upon the intensity of the 
suppuration. When the latter is very abundant, notably 
at periods of exacerbation, they come in to diminish it and 
even at times dry up the discharge. Still they have too 
unfavorable an action upon the stomach and kidneys for 
their employment to be highly recommended. They have, 
besides, a slightly astringent action. 

We employ the balsam of copaiba (Chopart i^otion), 
but because of its very disagreeable taste, it is better to 
prescribe it in capsules, of which the patient should take 
six to ten or fifteen in the twenty -four hours. 

Cubebs is taken in capsules of from one to three grams 
three times a day. We may also combine copaiba with 
cubebs as in the following formula: 

1$; Copaivas, 15.0 

Cubebse, 20-30.0 

Spt. Menth. pip q. s. to form a paste 

of which the patient takes in a wafer a piece the size of a 
large hazel-nut three times a day. [We prefer to have 
this mass divided into sixty gelatine capsules, of which 
three should be taken three times a day.] 

Santal oil is perhaps the most highly recommended of 
the balsamics (1-3 grams daily.) It finds its field of use- 
fulness largely in patients whose canal is very sensitive, 
and who stand local treatment badly. Most generally, 
however, all these drugs are prescribed " ut aliquid fecisse 
videatur." Their action, when it really exists, is ex- 
hausted at the end of one or two weeks. [Santal oil is best 
given either in capsules, or to not fastidious patients in the 
form of an emulsion. 

fy 01. Santali 10.0 

01. Cinnamomi gtt. x 

Pulv. Gummi Arab 4.0 

Syr. Simpl 15.0 

Aquae ad 65.0 

M. D. S. Teaspoonful three times a day.] 



158 CHRONIC URETHRITIS 

Urinary antiseptics (salol, methylene blue, etc.) have 
scarcely any action in the chronic forms of gonorrhea, 
because the antiseptic power which they communicate to 
the urine is too feeble to reach the gonococei, which have 
generally penetrated into the substance of the tissues. 
They may be useful in acute recurrences. Undoubtedly 
because of the slightly bactericidal effects, and especially 
because they are absolutely nou- irritant. 

[To these so-called urinary antiseptics belong the sali- 
cylates in their several forms, as salicylate of soda, sali- 
pyrin, ol. gaultheria?. They separate carbolic acid, and 
by thus inhibiting the growth of micro-organisms in the 
urine, render it less irritating to the inflamed surfaces 
of the bladder and urethra. They keep up at the same 
time an acid reaction, and so prevent ammoniacal decom- 
position. It is necessary, especially in subacute urethritis, 
to keep up an acid reaction to prevent cystitis. Finger 
has recently called attention to this fact and to the great 
mistake one makes by the routine administration of alka- 
line mineral waters in cases of urethro- cystitis compli- 
cating gonorrhea. Such a course will only add to the 
tendency of ammoniacal decomposition aided by an alka- 
line reaction of the urine. 

The salicylates are undoubtedly of great value, but until 
recently salol has headed the list as an urinary antiseptic. 
But in some individuals it separates carbolic acid so freely 
as to render the urine an olive green color, setting up an 
irritation of the kidney epithelium and causing temporary 
albuminuria. In the introduction by Nicolaier of a prepa- 
ration called Urotropin, we have a drug which has none of 
the drawbacks of the salicylates, and possesses a much more 
powerful germicidal, sterilizing, and antiseptic action. It 
renders ammoniacal urine acid, is almost a specific for 
phosphaturia, retards decomposition of residual urine, in- 
hibits the growth of bacteria in the prostatic follicles, and 
proves of great service in bacteruria. 



GENERAL TREATMENT 159 

Urotropin acts by liberating in the urine, under the in- 
fluence of uric acid, formaldehyde, which is inimical to all 
bacterial growth. The dose is five to ten grains three 
times a day in water. It is therefore advisable to admin- 
ister a dose or two of the drug to such patients as are 
prone to develop urethral fever even when aseptic instru- 
mentation has been practiced. It will surely supersede 
the time -honored dose of quinine recommended for that 
purpose. Urotropin is of exceptional value in all the 
suppurative diseases of the genito-urinary tract. It is 
only in tubercular diseases that its influence has not proven 
so beneficial. We will make extensive use of it in sub- 
acute exacerbations of chronic posterior urethritis and 
urethro- cystitis, where instrumentation is absolutely con- 
tra-indicated. By arresting ammoniacal decomposition it 
will relieve the painful urinary tenesmus, and aid materially 
to shorten such incidents, after the decline of which proper 
treatment by washing and dilatation can again be re- 
sorted to.] 

Nervines act as calming remedies to the nervous 
system; we use, by preference, those which have an action 
upon the genital sphere. They are often of great use when 
there is a posterior urethritis, when they rapidly calm 
painful and allay disagreeable symptoms. They are, there- 
fore, useful adjuvants of the local treatment, whose dis- 
agreeable effects they help to mitigate. They include 
the bromides, the narcotics, opium and belladonna, which 
are of very great activity. Some vegetable fluid extracts 
may also act as calming remedies of moderate effect, 
capable of diminishing nervous excitability. Among the 
latter, we will cite Kawa-Kawa, and Salix Nigra. We 
prescribe the fluid extract of Piper Metliysticum (Kawa) 
in dose of one and a half to four grams, two or three times 
a day, in a glass of water after meals; or, fluid extract of 
the buds of Salix Nigra, one or two teaspoonfuls in a glass 
of water three times a day at meal- time. 



160. CHRONIC URETHRITIS 

[In employing' morphine hypodermically in urinary 
tenesmus, Finger points out that we should not go beyond 
one -third of a grain, as morphine in larger doses causes 
tenesmus. Mention may be made here of morphine and 
belladonna suppositories, and of the sedative influence of 
hyosciamus and cannabis. 

1^ Extr. Hyosciarni. 

Extr. Cannabis Ind. aa., ... .0.03 

Sachari, 0.06 

M. D. tal. Dos. Xo. xii. 
S. 3-4 powders t. i. d. 

A large draught of flaxseed tea alternating with a 
decoction of folia? uvae ursi, has undoubtedly a very calm- 
ing effect on the posterior urethra. It is by no means an 
obsolete medication, and is certainly worthy of a trial as 
an adjuvant in painful tenesmus.] 



CHAPTER X 

LOCAL TREATMENT 

The local is the only treatment upon which one can 
rely to bring* about a cure of the lesions of chronic ure- 
thritis. It includes the employment of medicinal sub- 
stances applied directly to the canal, and the purely me- 
chanical treatment. These two methods may furthermore 
be combined. 

Methods. — To introduce a drug into the urethra we 
generally employ the method of injections. 

I. Injections. — The following is the method of urethral 
injection as described by Diday: "Standing up or sitting 
upon the side of an arm-chair, the penis held erect, seize 
the syringe by the upper part of the barrel between the 
thumb and the right index, the index being placed upon 
the knob or within the ring of the piston; introduce the 
point from ten to twelve millimeters within the meatus, 
whose borders are pinched together by the thumb and 
index of the left hand, and draw this border to one side 
in such a way that it covers over the point of the syringe, 
to prevent a return flow of the liquid as the latter is in- 
jected. Now push the piston so as to empty the syringe in 
two or three seconds; then in withdrawing it press the 
meatus forcibly between the tips of the index and middle 
fingers of the right hand; wait a minute in this position; 
finally force the fluid backward by pressing the penis from 
above downward between the two fingers of the right hand, 
then between the two fingers of the left hand alternately, 
and successively carry the one behind the other, from 
the meatus to a point just in front of the scrotum, by a 

K (161) 



162 



CHRONIC URETHRITIS 



movement analogous to that carried out by a man mount- 
ing a ladder in seizing alternately the rungs one after 
another." 

We do not strongly advise this last maneuver, which 
can have no other result than to cause the fluids to flow 
into the posterior urethra where they should not penetrate. 
When the posterior urethra is affected, we prefer the 
method of deep washing or lavage. As to the instrument, 
we advise the use of a good glass syringe with a proper 
piston and a rounded tip which cannot wound the canal. 
This method of injection is most usually employed. It acts 
well in chronic urethritis with solutions which are not too 
energetic and which can, without inconvenience, be applied 
to the whole anterior urethra. 

II. Instillations. — When we desire to employ more 
active solutions, it is no longer possible to send them by 




Fig. 23. GrTTYON's Instillation Syringe and Perforated Explorer. 



chance into the whole canal in considerable quantity. It is 
better to deposit the fluid at the diseased points, and we 
generally employ with this intention the method of instilla- 
tion described by Guyon as follows: 

"The instruments necessary are very simple. They 
include a. graduated syringe (Fig. 23, A), to contain sev- 
eral grams of fluid, and a perforated, flexible, olive -tipped 
explorer made of gum -elastic (Fig. 23, B) . 

"The syringe should be furnished with a conical cannula 
having an external screw furrow; the perforation of the 
olive tip on the explorer should be centrally situated and 



LOCAL TREATMENT 1G3 

quite small. The piston of the syringe should be worked 
like that of the old Pravaz syringe, by successive turns of 
a screw and not by pressure. It is a mistake of instru- 
ment-makers to apply to the instillation syringe this useful 
modification of the piston which has been adopted for the 
hypodermic syringe. The syringe is filled with the solution 
desired, and then screwed fast to the extremity of the stem 
of the exploring bulb, to which it should fit closely. 

''Before introducing the instrument into the canal it 
should be primed; the stem of the explorer holds a certain 
quantity of fluid. The syringe is to be filled exactly, so 
that, with each half turn of the screw, there should escape 
from the small opening in the bulb one drop of solution. 
If the connection between the explorer and the cannula is 
perfect, the liquid can escape only when the piston is put 
into motion; it is to secure this result that the cannula is 
conical and supplied on its exterior with a screw furrow." 

With the method described by Guyon we can deposit a 
few drops of fluid in the bulbar region "or in the posterior 
urethra. The olive tip permits one to distinctly recognize 
the moment the external sphincter is reached, and to know 
with precision whether the fluid is deposited beyond or 
upon this side of the sphincter. If we desire to make local 
applications with greater precision, we must employ the 
urethroscope, aud touch the diseased point by means of a 
cotton -swab wound on an applicator and moistened with 
the desired solution. 

[Instillation, that is the application of caustic solutions 
to a limited area, are used for both the anterior and pos- 
terior urethra. We are of the opinion that, as to the 
anterior urethra, it is wholly unnecessary. Anterior in- 
stillation is performed by introducing the instillator, of 
whatever description, down to the bulbar sinus, ejecting the 
remedy as the instrument is slowly withdrawn. The liquid 
will escape from the meatus, after it comes in contact, not 
only with the isolated patches, but with the whole surface 



164 CHRONIC URETHRITIS 

of the anterior mucosa. In our opinion this is nothing 
else but a retroinjection. Nothing is accomplished by 
anterior instillation which is not better done by the method 
of injection. The aim of touching a diseased spot only, 
although very rarely attained and well-nigh impossible, is 
not accomplished. The consensus of opinion as it now 
prevails is, not to use any instrument if we are able to gain 
our object without it. Injection by the hand syringe 
with a solution of the same strength, will not only act 
similarly, but will supersede anterior instillation in so far 
that under the well -graded pressure it distends the anterior 
urethra and allows the liquid to reach or even penetrate in 
the follicles. In order to localize with absolute certainty, 
we have to resort to applications through the urethroscope. 
In making instillation to the membranous or prostatic 
portion of the urethra, we encounter somewhat different 
conditions. It is well known that the posterior urethra 
will bear the application of stronger solutions better than 
the anterior. This may be due to the absence of a greater 
number of glands and lacunae or to the partly lesser surface 
which the posterior urethra offers to the influence of the 
remedy, or to the greater resistance of the epithelium in this 
region, or may perhaps be a combination of all these. The 
prostatic part is certaiuly endowed with a rich net -work 
of sensory nerves, and applications directly to it ought to 



Fia. 24. Ultzmann's Drop- Catheter. 

irritate more than such to the membranous portion. How- 
ever this may be, the posterior urethra, at least the pars 
nuda, is less receptive toward cauterizations than the 
anterior. 

In performing these instillations we make use of differ- 



LOCAL TREATMENT 165 

ent instruments that will serve the same purpose with more 
or less aptitude. Guyon's instrument possesses the great 
advantage of permitting exact localization by means of its 
bulb, but we have to enlist the aid of the patient to hold it 
in place while working it. Ultzmann's drop -catheter (Fig. 
24) consists of a silver catheter with a capillary lumen and 
a short curve. Its distal end bears a hard rubber capping, 




"=i\QW\-NVM<W.VY MV^.SlC&. 




>'ig. 25. Keyes' Deep Urethral Syringe. 

into which fits an ordinary hypodermic syringe, the piston 
of which is graduated in minims. In Keyes' modification 
the instrument is solid in one piece (Fig. 25) . The two lat- 
ter instruments are easier of introduction and of handling, 
but being smooth they do not convey to the fingers that 
fine touch which Guyon's bulb instillator imparts. Fried- 
laender has recently devised a combination of Guyon's and 
Ultzmann's syringes by having the silver catheter end in 
a small bulb. We do not think any stiff -shafted bulb will 
answer so well as a bulb on a flexible elastic catheter. 

Moreover, as we will localize lesions with the elastic 
bougie a boule before instillation is made, the selection be- 
tween the two first -named instruments or their modifica- 
tions will be more or less a matter of personal predilection. 
We do the work with the Ultzmann, as well as with the 
Keyes instruments. We have some predilection to the 
former, because we like the detachable syringe. The de- 
sired amount of a one to five per cent solution of nitrate of 
silver is drawn into the syringe, and the drop -catheter at- 
tached to it. The liquid is now propelled forward until the 
air is expelled, and the first drop appears on the visceral 
end of either the bulbous, elastic, or silver drop-catheter. 



166 CHRONIC URETHRITIS 

It is our custom now to" withdraw the plunger a trifle, so as 
to aspirate this drop back into the catheter. The vacuum 
so created holds the column of liquid in an equilibrium, 
and prevents its escape while introducing the instrument 
through the anterior urethra. The catheter tip is now 
wiped with a piece of sterilized gauze, and the instrument 
lubricated with glycerin. As the catheter reaches the 
bulbous part of the canal, the outer end of the instrument, 
according to the rules of catheterization, is raised and 
gently pressed downward, making the tip inside pass the 
triangular ligament, and enter the membranous part. 
The long axis of the instrument is now 45° from the 
vertical. In order to reach the prostatic portion, a down- 
ward pressure of the shaft of about 10° more, or about 
three-quarters of an inch is necessary. If the application 
has been properly made, none of the injected fluid will 
return through the meatus. An imperative desire to 
urinate and, when the prostatic portion has been touched, 
to defecate, will soon be felt by the patient. We prefer 
not to have the patient void his entire urine prior to 
the instillation. This will expose the neck of the* bladder 
readily enough to the influence of the injected fluid, while 
a little residual urine in the bladder will save its mucosa 
from the caustic effect of the silver. By the chemical change 
which the silver undergoes with the urine, non -irritating 
chloride of silver is formed, which will not irritate the 
mucosa of the bladder and that of the anterior urethra 
when the strong desire to urinate has set in. 

There is one proviso we would like to emphasize. After 
instillation has been performed, there adheres to the cath- 
eter a drop or so of silver, which is necessarily brought 
in contact with the anterior urethra when the instrument 
is removed. It is our practice to again aspirate it into 
the catheter by slightly withdrawing the piston, in 
order to clear the tip of the instrument of adherent fluid. 
By this simple maneuver the anterior canal will not get 



LOCAL TREATMENT 167 

any of the silver unnecessarily when the instrument 
is removed.] 

III. Lavages. — When we wish to employ considerable 
quantities of fluid, or desire to affect at the same time 
both portions of the urethra, we employ the method of 
lavage. 

In order to proceed with deep washings without cathe- 
ter, as described by Van den Abeele and recently brought 
into favor by Janet, we employ an Esmarch irrigator placed 
at about one or one and a half meters above the level of 
the canal. The tube of this irrigator is applied to the 
meatus in such a way as to entirely fill out the latter so 
that the liquid flows readily into the urethra. Janet has 
described a special tube which adapts itself admirably to 
this purpose. When the medicated fluid has filled and dis- 
tended the anterior urethra, it forces the external sphincter 
and penetrates through the posterior urethra into the 
bladder. As soon as the latter contains a certain quantity 
of fluid, the patient urinates and so projects again the 
medicated liquid into the canal. At times the influx of 
fluid into the posterior urethra is accomplished only with 
much difficulty, but in this case we must urge the patient 
to relax the sphincter as though he would urinate. In this 
way the passage is facilitated. This procedure of irrigation 
is not without inconveniences. For this reason we pre- 
fer irrigation by means of a catheter. We may employ one 
of the many forms of catheters invented for this purpose; 
the models of Ultzmann and Oberlander [silver catheters 
with slit openings or with perforations] are those generally 
employed. It is still more simple to use the Nelaton 
catheter (numbers 12 to 15 Ch.). 

When the eye of this catheter rests in the urethral 
canal, and the pressure by the syringe is not too excessive, 
the liquid will flow back along the walls of the catheter 
toward the meatus, if its eye lies in the anterior urethra; 
it will, on the contrary, flow toward the bladder, as soon 



168 CHRONIC URETHRITIS 

as the eye of the catheter has passed the external sphinc- 
ter. If we desire to irrigate the anterior urethra alone, the 
catheter is to be introduced until the resistance offered by 
the sphincter indicates that it has come to the bottom of 
the bulbar region. We may then, by means of a syringe 
of appropriate dimensions, and under moderate pressure, in- 
ject an astringent solution or one of antiseptic or caustic 
nature, and thus irrigate the whole anterior portion of the 
canal, whose mucous membrane will be spread out by 
reason of the presence of the rubber tube in the canal. 
If the catheter passes beyond the sphincter, the liquid 
will, on the contrary, flow over the posterior urethra. 

Finally, we may combine these two maneuvers, irrigate 
first the posterior region of the canal; then, withdrawing 
the catheter a few millimeters, act upon the anterior 
urethra. In drawing the prepuce forward beyond the 
meatus and holding it closed by means of pressure of two 
fingers, we can distend the balano- preputial region and 
irrigate it at the same time; this maneuvre is often one of 
great value. 

Such are the proceedings most generally employed at 
the present time for introducing to the urethra such medi- 
cated solutions as we wish to use in acting upon the sur- 
face of the mucous membrane. There exist still other 
local methods of treatment: suppositories or melting 
bougies, antrophores, applications by means of porte- 
caustiques, etc., but they are scarcely capable of such 
general employment, and have no advantages over the 
methods which we have described. 

Mechanical Treatment (the use of bougies and 
dilators). — This should also be described here as a method 
of local treatment. However, by reason of its great impor- 
tance, we will devote a special chapter to its consideration. 
(See Chap. XIII). 

[Since the treatment of chronic urethritis, besides in- 
stillations, mainly consists in flushings or irrigations and 



LOCAL TREATMENT 169 

in the introduction of instruments, a few notes on the use 
of the former may be ventured here. Since the revival by 
Janet of the irrigations in the treatment of acute gonor- 
rheal urethritis, the somewhat promiscuous employment of 
irrigation has come into use. It is not our intention to 
dilate here on the merits of the method in acute urethritis, 
but risk a few remarks on iriigation and on the irrigation 
apparatus in the treatment of chronic gonorrheal urethritis. 
In conjunction with other observers, we are of the opinion 
that irrigation, or flushing or washing, as we may call 
copious injections, can be practiced more safely and simply 
with the large hand syringe. The most ingeniously con- 
structed stop -cock of an irrigator will fail to carry to the 
hand that subtle sensation of resistance which the hand 
syringe will impart. Even in skilful hands the hydro- 
static pressure by an irrigator, placed from three to five 
feet high, has caused, with rebellious compressors, edema, 
ischiuria, and hemorrhages. Chalot has observed in his 
clinic two cases of rupture of the bladder, after the use of 
the irrigator, one of which proved fatal. We had occasion 
to note a few cases, where, in spite of the greatest care 
exercised, urethro- cystitis and hemorrhage have occurred, 
coupled with painful tenesmus, and in some instances a 
paretic condition of the compressor muscle. Such and 
similar incidents have somewhat dampened our enthusiasm 
for the irrigator, to the use of which we were very partial. 
Since performing washings with the hand syringe, such 
untoward effects have ceased to occur. 

This is easily explained by the fact that the hand 
syringe permits us to grade the propelling force of the in- 
jection with perfect accuracy. The thumb on the piston 
is en rapport with the patient, and imparts to it imme- 
diately that delicate sensation of resistance caused by the 
contraction of the compressor urethras muscle when the 
fluid strikes it. The theory of washing the anterior 
urethra without catheter is based on this sudden impulse 



170 CHRONIC URETHRITIS 

which keeps the muscle closed. If we now stop injecting, 
and release the grasp on the meatus somewhat, while re- 
taining the syringe in place, thus allowing the fluid to 
escape alongside the nozzle, then none will enter the pos- 
terior urethra. Thus the anterior urethra is cleansed. We 
have shown elsewhere the method of washing the pos- 
terior urethra. The maneuvers are the same as recom- 
mended by Janet. In using the hand syringe we have 
found that the relaxation of the compressor is synchronous 
with the height of expiration. It is best to push the 
piston cautiously forward at this moment. 

Some observers are in the habit of using the hand 
syringe with preference, but attach a soft catheter to it for 
the purpose of dilating the urethra when flushing it. This 
is unnecessary. In anterior irrigation the fluid will balloon 
up the urethra, and spread out all its folds sufficiently by 
reason of the lrydrostatic pressure, augmented by the 
counter -pressure of the contracting compressor muscle. In 
irrigating the posterior urethra with the hand syringe, a 
little experience will enable one to cause the fluid to enter 
the bladder without a catheter by observing the rules before 
mentioned. We should avoid, whenever possible, insert- 
ing instruments, even when asepsis is practiced studiously. 

Generally speaking, with some exceptions, most forms 
of chronic urethritis will permit this method of washing 
without catheter. It is held that stronger solutions 
should not be applied to the canal in its entirety, touching 
diseased as well as healthy spots. While this is true of 
very concentrated solutions of nitrate of silver (one to five 
per cent), or sulphate of copper (one to fifteen per cent), 
when used as instillations, it is perfectly permissible to 
nse for washing of the entire canal solutions of nitrate of 
silver in the strength of from 1 in 4,000 to 1 in 1,000. 
In fact this is often done by all those who are using the 
method of Diday, which consists in introducing a catheter 
into the posterior urethra, for irrigation, and then by 



LOCAL TREATMENT 111 

slowly withdrawing it to allow the fluid to escape through 
the anterior. 

We will therefore use washings with the hand syringe 
in chronic anterior urethritis of a diffuse character, when 
the first urine is cloudy, or in diffuse urethritis, anterior 
and posterior, with both portions cloudy; or when the 
bladder is involved in connection with an anterior and pos- 
terior urethritis. Of course we will first employ the neces- 
sary two- three- and five -glass tests, preceded by wash- 
ings of the canal to determine the location. Even those 
localized stages of chronic urethritis, where threads are 
abundant in a clear first or second urine, will be benefited 
by flushing with solutions of medium strength. In these 
latter cases, however, when threads appear with some con- 
stancy in spite of flushing, and the bougie a boule or the 
urethrometer has revealed spots where pain is felt, and the 
dilatability of the canal is impaired, we will have recourse 
to topical applications. We will then touch those spots 
with a mounted cotton -carrier through the urethroscope, 
when situated in the anterior, or use instillations (Ultz- 
mann's "etchings") when in the posterior urethra. In 
those cases of posterior urethritis known as urethro- 
cystitis, popularly called inflammation of the neck of the 
bladder, without involvement of the anterior canal, wash- 
ings performed after Diday's method might prove pref- 
erable. Here the compressor may yield more easily to the 
catheter than to the pressure of the injection fluid. Here 
again the superiority of the hand syringe will show itself. 

The hand syringe we use (Fig. 5, p. 57), is the 
one originally known as the Janet-Frank syringe. Its 
plunger consists of an inflatable rubber ring, or of sev- 
eral rubber disks, controlled by a screw connected with 
the piston-rod, which governs its expansion. The syringe 
has a capacity of 150 grams (five ounces) and is perfectly 
sterilizable. An olive-shaped nozzle (Fig. 5, p. 57) of soft 
rubber is put on the tip of it. This nozzle by reason of 



172 CHRONIC URETHRITIS 

its shape fits perfectly into the meatus. Such nozzles can 
be boiled or kept in a bichloride solution, 1 in 1,000. 
Each patient must have a separate one for himself. They 
are best kept in envelopes with the name of the patient 
thereon. We will dwell upon this point in a separate 
chapter. 

As to the other details, they are almost identical with 
those when using the irrigator. The patient, after drop- 
ping his trousers below the knee, sits on a chair well 
toward the edge, leaning his shoulders against the back of 
it, his legs well spread and holding a basin between them. 
The physician stands on the right side of the patient, 
grasping the penis with his left hand. We claim that the 
hand syringe, besides the advantages mentioned before, 
possesses the additional advantage of simplicity and easi- 
ness in handling. Even the head of the celebrated French 
school of genito- urinary diseases, Guy on, where Janet ex- 
pounded his irrigation treatment, calls the hand syringe an 
"instrument de precision."] 

Topical Remedies. — We can divide the class of reme- 
dies employed topically in the urethra into three classes: 
Astringents, caustics, and antiseptics. We shall briefly 
pass in review the chief ones among them, and point out 
their properties and general indications for their use. The 
choice which we will make will often depend upon the per- 
sonal preferences of the practitioner, and upon the experi- 
ence he has had with the various methods. 

I. Astringents. — Astringents are certainly the products 
most universally employed. They comprise a considerable 
number of remedies from the vegetable as well as the 
mineral kingdom; from rose-water to sulphate of copper. 
They are generally employed as simple injections, but rarely 
as instillations. They have also been advised in the form 
of lavages. They have also served under other forms: dry 
powders distributed by means of a small tube to the sup- 
posed point of disease; pomades with which the sounds 



LOCAL TREATMENT 173 

are smeared, and thus introduced into the urethra; gelatin 
bougies melting in the canal under the influence of the 
body's heat, etc. 

The sulphate of zinc is the prototype of astringents. In 
appropriate doses it gives excellent results. A one percent 
solution is used two or three times a day . The acetate of 
zinc and the permanganate of zinc are employed in about 
the same strength and have the same action. 

The acetate of lead is likewise prescribed. Generally 
their action is combined. Ricord's injection is an example: 

^ Zinei Sulphat 1.0 

Plumbi Subaeetat 2.0 

Tinet. Catechu 

Tinct. Opii aa 4.0 

Aq. Kosae (or aq. fontis) 200.0 

The sulphate of copper is employed in w r eaker solution 
(1 in 1,000). It is more caustic than the preceding. 

[The use of any of these remedies at the proper time 
would be of great benefit to the patient, and a source of 
satisfaction to the physician. But we must confess that 
hitherto the indications for their employment have been so 
vague that it borders almost on intuition to choose the 
right one. We are, therefore, indebted to Finger, who quite 
recently expounded the use of nitrate of silver and sulphate 
of copper in chronic gonorrheal urethritis. For the recent 
superficial lesions, because only such are amenable to 
injections or instillations, he recommends the nitrate of 
silver; for older ones, the sulphate of copper. He draws a 
happy parallel with the treatment of trachoma of the con- 
junctiva. There the catarrhal symptoms are combated 
with silver, while the older processes are attacked with the 
sulphate of copper in substance. The same indications 
hold good for chronic urethritis, with this modification: 
In recent cases of chronic urethritis, where gonocci are yet 
present, nitrate of silver should be employed; in inveterate 



174 CHRONIC URETHRITIS 

cases, where no gonococci are present in the filaments, the 
sulphate of copper will prove effective. The nitrate of 
silver in one -half to five per cent, the sulphate of copper 
in five to ten per cent solutions. 

It is best to begin with the milder percentages in order 
to test the reaction of the urethra. If stronger solutions 
are well borne, we will employ a glycerin solution of them 
instead of an aqueous one. The glycerin possesses great 
affinity for moisture, and will imbibe deeper than a watery 
vehicle. Finger recommends also the use of a lanolin salve 
to be used through Tommasoli's salve syringe. 

1^ Lanolini 95.0 

Olli. oliv 5.0 

Argenti. nitr. 

or cupri. sulphatis J 0.5, 1.0, to 5.0 

12.0, 5.0, to 20.0 

In this vehicle the drug adheres very closely to the 
mucosa.] 

The action of astringents. seems to be as follows: They 
harden the superficial layers of the epithelium, and thus 
form a more resistant covering, underneath which a healthy 
epithelium may develop. Thus they are especially useful 
in mucous catarrh, whether the latter exists alone or accom- 
panied by other urethral lesions. Their effect is then 
marked by a rapid diminution and at times by a complete 
disappearance of the purulent discharge. They may also, 
possibly, penetrate into the glandular cavities, and have an 
analogous action upon their epithelium. But they are 
naturally without action upon the deep infiltration, 
especially when the latter have passed into the fibrous 
state. 

[By mucous aseptic catarrh is meant that rare form of 
catarrhal discharge from the urethra not caused by gono- 
cocci or other pyogenic bacteria. This, mostly scanty, 
discharge consists of mucus and some epithelium. It is 
called, therefore, an aseptic discharge. It can be met with 



LOCAL TREATMENT 175 

frequently as a post -gonorrheal secretion when the 
gonococci have vanished. It is here that the astringents 
prove most useful — zinci-sulphocarbolici, one -half to one 
per cent, for instance. In this case we may apply injections 
in form of suspensions. In Ricord's mixture soluble 
zincum aceticum is formed, while the insoluble plumbum 
sulphuricum precipitates on the surface of the mucous 
membrane. A still better formula is: 

fy Bismuth 5.0 

Aquae, or Glycerin 180.0 

M. To be well shaken. 

This should be injected before retiring. The bismuth 
will precipitate, and has a chance to remain in contact with 
the mucosa for several hours. It acts mechanically, and by 
being solved out slowly it thus exerts an astringent and 
slightly caustic influence, which restores slight lesions of 
the mucosa rapidly. 

The reflex contraction of the vessels in the mucosa 
under the influence of an astringent, causes a cessation of 
the diapedesis of leucocytes. The consequence is a dimin- 
ished secretion. We know of no valid reason why we 
should expect even the slightest action from them on infil- 
trations. Applied in weak solutions, they will, in addition, 
lessen the hyperemia, an action we are wont to call anti- 
catarrhal. In stronger solutions they will exert a caustic 
action of a lower grade, especially when the sluggishness 
of the process needs an alterative.] 

II. Caustics are the topical applications employed in 
the treatment of chronic gonorrheal urethritis. Caustics 
are the most energetic, and give the best results. But we 
must know how to employ them properly and not in 
excessive dosage. 

The prototype of caustics is the nitrate of silver. It is 
generally employed as instillation or lavage. 

The instillation of nitrate of silver in strength varying 



176 CHRONIC URETHRITIS 

from 1 in 200 to 1 in 50, and even 1 in 30 have been 
especially recommended by Gnyon. The method described 
by this author, and which has been widely used, gives in 
many cases good results. It is almost never necessary to 
exceed a strength of one per cent. We use nitrate of silver 
also in lavages (0.25 to 1 in 1000). These lavages have 
the decided advantage over instillations of greater concen- 
tration, of being less painful. Therefore they are highly 
recommended in the treatment of posterior urethritis. We 
also employ them in the treatment of anterior urethritis at 
the same time when mechanical treatment of the latter is 
indicated. 

We can assure ourselves of the effect of nitrate of silver 
injections by means of an urethroscopic inspection of the 
canal a short time after the injection. 

We note in this way that the nitrate of silver has 
produced upon the surface of the mucous membrane an 
escharotic effect. After a lavage by means of a solution 
of 1 in 1000, the membrane takes on a quite uniform gray- 
ish white color, spread over the whole extent of the canal. 
In stronger solution (instillations of one per cent) the 
color is still more marked and, furthermore, the mem- 
brane seems harsh and as though starched. At the end of 
twenty-four hours the normal color returns in plaques, then 
the grayish aspect disappears rapidly, the summit of the 
folds of the mucous membrane keeping the grayish color 
the longest. 

This elimination of the eschar is naturally accompanied 
by a suppuration whose abundance is increased according 
to the concentration of the solution employed. Thus there 
runs from the canal a sort of creamy pus of yellowish white 
color. 

Cauterizations with nitrate of silver have an energetic 
action on the superficial lesions, but they have naturally 
only a feeble effect upon the deeper ones. However, the 
abundant suppuration which they set up should have a 



LOCAL TREATMENT 177 

certain influence upon the parvieellular infiltrations, even 
when the latter have their seat in the deeper tissues. They 
may, even up to a certain point, provoke their absorption. 

When the use of nitrate of silver has been too pro- 
longed, the mucous membrane becomes penetrated by the 
reduced salts of silver and takes on a blackish gray color 
constituting argyrosis. 

The use of very strong solutions (10 per cent) has 
been also advised in application to very limited areas by 
means of the instillator, or of t\\e porte caustique, or under 
the control of the urethroscope. This procedure may be 
indicated when it is a question of destroying such lesions 
as granulations, or small polypi, etc. But we must be on 
our guard against too deep cauterization, capable of de- 
stroying the mucosa. Aside from the nitrate of silver, 
chromic acid, sulphate of copper, etc., have been used. 
They are perhaps less to be recommended. Employed in 
feeble solution, caustics act like astringents. 

III. Antiseptics. — When the infectious nature of gon- 
orrhea was recognized, the greatest hopes were built up 
on the action of antiseptics. These hopes have unfortu- 
nately been but feebly realized. If the action of bacteri- 
cides can be very energetic in acute urethritis, when these 
remedies are judiciously employed, this is far from being 
the case in the chronic forms. Here the lesions of the 
mucosa are already in existence, the microorganism has 
penetrated into the substance of the tissues and into the 
glandular cavities, and we cannot count upon the action of 
an antiseptic to destroy it. Furthermore, employed in 
strong solution, the most energetic antiseptics have an 
irritating and destructive action; they cannot, therefore, 
be employed in concentrated form in the canal, and if used 
in weak solution they are inactive. Among them, the 
nitrate of silver, whose caustic action we have just studied, 
seems also to play the most energetic role as a bactericide. 
Thus it bears a double recommendation. Corrosive subli- 



178 CHRONIC URETHRITIS 

mate (1 in 20,000 to 1 in 10,000) has recently been advo- 
cated, as well as the permanganate of potassium (1 in 2,000 
to 1 in 1,000). We use these two remedies as injection or 
in lavage. We can employ them with advantage, es- 
pecially during aente recurrences which often accompany 
the treatment of chronic forms. They then act as slight 
caustics at the same time, and diminish or even arrest 
suppuration. 

[We may be permitted to mention here that it was Dr, 
Wm. S. Halstead, of New York, who, we think, in 1884 
suggested and first practiced the irrigation of the urethra 
(in acute gonorrhea) with a weak solution of bichloride of 
mercury. Already in 1880 Otis advocated its use in con- 
nection with Dr. Holbrook Curtis 's advice of hot retro- 
injections by means of a fountain syringe. Bichloride 
irrigations have since been adopted in the treatment of 
chronic gonorrhea.] 

When the exacerbation is very violent, it is best to 
employ still less irritating antiseptics such as resorcin 
(2 in 100) , and sulpho-ichthyolate of ammonium (2 in 100) , 
as injections (three or four times daily), or as lavage. 
Finally we may employ such combinations as: 

1^ Zinci sulphatis 
Aluminis 

Acidi carbolici, aa 0.30, 0.50 

Aqua? 125. 

Or, 

I$( Potassii permanganitis 1 

Argenti nitritis 1 

Aquae 2,000 

This last mixture should be prepared extemporaneously 
by taking a solution of permanganate (1 per cent), and a 
solution of nitrate of silver of the same strength. The 
two solutions are to be mixed together at the time of 
injection.^ 



CHAPTER XI 

NOTES ON THE TREATMENT OF CHRONIC GONORRHEA* 

[We cannot help referring to the acute stage of gonor- 
rhea in a volume dedicated to the chronic manifestations of 
the disease. Inasmuch as chronic gonorrhea is a sequel of 
the acute, we think that if the etiologic treatment of that 
stage were taken up as speedily as possible, it would 
diminish the number of cases of acute posterior urethritis 
and, incidentally, chronic urethritis. Finger notes in his 
latest publication (Die moderne Therapie der Gonorrhea, 
Vienna, 1900), the great advantage of such treatment. 
Those cases that have been treated with Protargol and 
Largin (one -quarter to one per cent) for the first week or 
ten days, followed by the use of antiseptic astringents like 
nitrate of silver or argentamine in 1 in 2,000 solutions, 
developed posterior urethritis only in very rare instances. 
While this complication will take place in seventy to eighty 
per cent of cases otherwise treated, we will find it only in 
forty per cent in cases treated with Protargol, and in thirty 
per cent treated with Largin. In the face of such statistics, 
and of our own experience, we are of the opinion that we 
possess in these salts a prophylactic remedy, which will 
limit the occurrence of chronic gonorrhea with its in- 
tractable complications. 

In endeavoring to treat chronic gonorrheal urethritis 
according to the indications offered, we must try to deter- 
mine, before all, the localization — whether anterior or pos- 
terior, and in the latter event, whether, and if so in what 
measure, the Cowper's glands, 'the prostate and seminal 



*By the Editor. 

(179) 



180 CHRONIC URETHRITIS 

vesicles are involved. It is somewhat surprising that 
chronic urethritis is mostly associated in the mind with a 
process invading the posterior urethra. This is a mistaken 
notion, for the anterior urethra is affected almost twice as 
often as the posterior. A favorite site is the bulbous 
region. This is probably due to a latency of the process 
in this region, causing a very scanty suppuration to appear. 
The case is then thought cured, while yet in need of treat- 
ment. The site of predilection for chronic posterior ure- 
thritis is the prostatic part. The different methods of 
localizing the process have been dwelt upon elsewhere, and 
concerning treatment scarcely anything new can be com- 
municated. But mention must be made of the new silver- 
salts which play such an eminent role in the treatment of 
the acute stage. These are Argonin, Argentamin, Protar- 
gol, and Largin. 

It is a well known fact that the new salts of silver do 
not change their chemical properties when in contact with 
the mucous membrane of the urethra. This chemical sta- 
bility enables them to penetrate unchanged into the sub- 
epithelial layers, thus exerting their anti- parasitic powers 
in localities otherwise impermeable to other agents not 
possessing this virtue of penetration. The latest prepara- 
tion of silver which promises these properties is the Pro- 
targol, introduced by Neisser. It occurs as a yellowish 
fine powder, readily soluble in cold, as well as in hot 
water, by agitation. It is a chemical combination of silver 
with a proteid, i. e., a silver abuminate. It differs from 
Argonin, which contains four and two -tenths per cent of 
nitrate of silver, in that its solution remains clear. It con- 
tains eight and three -tenths per cent of nitrate of silver and 
stands between its fellow compound, the Argentamin, which 
contains ten per cent of nitrate of silver. Argonin is the 
mildest, and Argentamin the strongest amongst them, 
and the most irritating. Its bactericidal and penetrating 
power is most marked. Indications for its use are, there- 



TREATMENT OF CHRONIC GONORRHEA 181 

fore, chronic cases, where an irritant is of great service, by 
provoking a subacute inflammation, starting up a secre- 
tion and, with it, a dislodgment of latent gonococci. 
Argonin is used in a one to four per cent, Argentamin 
in from a one -sixth to one per cent solution, in acute 
gonorrhea. When Protargol took the place of Argonin, 
it did so by virtue of its possessing, as Neisser main- 
tains, greater penetrating power. It is evident that agents 
which do not enter into soluble combinations with the 
normal tissue-fluids, and are not precipitated by them, even 
when left in contact for any length of time, must have a 
great efficiency of action and power of penetration. 

Lately Largin has been introduced through Finger and 
Pezzoli. It contains 11.5 per cent of silver in the form of 
a para-nuclein proteid, soluble in water to the extent 
of 10.5 per cent. Its bactericidal power is greater than 
that of Protargol, but it is not as penetrating as Argenta- 
mine, although more so than Protargol. It has a slightly 
alkaline reaction which makes its application somewhat 
irritating. 

Finger recommends it in acute gonorrhea, after the 
acme of inflammation has passed, in the strength of one- 
fourth to one per cent solutions; in subacute posterior 
urethritis, as irrigation or instillation, in one -half to two 
per cent solutions. We have found it somewhat irritating. 
Among these silver -proteid salts, mostly Protargol and 
Argentamine are used in chronic gonorrhea. Finger, who 
gives to Protargol the first place in acute gonorrhea, dis- 
courages its use in the chronic form. Desnos and Nogues 
think it of greater value in chronic than in acute gonor- 
rhea. The first -named author uses it in five to fifteen 
per cent solutions, while Chettwood,* in sharing the same 
opinion, believes it very useful for posterior urethral instil- 
lation in solutions of from five to forty per cent, especially 



*Venereal Diseases, their Complications and Sequelce, by Edward L. Keyes and 
Charles H. Chettwood, New York. William Wood & Co., 1900. 



182 CHRONIC URETHRITIS 

when the mucosa alone is affected; or as an adjuvant to 
the permanganate irrigations when the deeper structures 
are involved; also in chronic prostatitis, where it in- 
fluences beneficially the surface inflammation. 

We regret the inability to entirely concur- in this view. 
Protargol will exert some influence on a mucosa in the 
state of chronic inflammation; but it can do this only bj r 
the very limited astringent power it possesses, if astringent 
properties it has at all. The lesions of chronic urethritis 
are circumscribed spots which persist after the acute dif- 
fuse process has run its course. These lesions may some- 
times not extend beyond the mucosa, producing erosions 
and granulations, or they may in other cases involve the 
submucous and adjacent tissues, causing periurethritis and 
cavernitis in the anterior, or prostatitis when the posterior 
urethra is affected. Lesions like these need a powerful 
astringent like nitrate of silver or sulphate of copper, 
in order to be influenced. Protargol is mainly antiseptic 
and bactericidal, as is Largin; the action of both be- 
ing enhanced by virtue of their unexcelled penetrating 
power. As thej^ do not form insoluble combinations of 
chloride of silver, they are not precipitated and, conse- 
quently, do not bar their own way to the deeper structures. 
This fact alone explains their efficacy in acute gonorrhea. 
Here the gonococci, after invading the urethra, traverse the 
epithelium and gain entrance to the superficial layer of the 
subepithelial tissue infesting the lacunas and Littre's glands. 

Finger calls this the first or purulent stage, because the 
secretion consists mainly of pus-cells carrying gonococci. 
They and their toxins cause a reactive inflammation of 
the mucous membrane, immigration of polynuclear leu- 
cocytes and of pus -serum through the permeable walls 
of the enlarged and inflamed vessels. He further points 
out, in his graphic way, that the gonococci bent on invad- 
ing the deeper structures create their own enemies, the 
pus -corpuscles. As these emerge from the depth to the 



TREATMENT OF CHRONIC GONORRHEA 183 

surface, the gonococci, in their downward journey, attack 
and invade them. Laden with gonococci, the leucocytes 
reach the surface and appear as purulent discharge. They 
actually float out the gonococci. The discharge, there- 
fore, is Nature's endeavor to rid itself of the gonococcus. 
In this connection we have expressed elsewhere (New 
York Medical Monatschrift, February, 1899, p. 54) some 
views which have recently been brought out that are 
founded on this process of elimination by Nature's power. 

It may seem somewhat reactionary, but certainly a very 
original view of Bloch (Berlin), when he maintains that it 
is unnecessary for us to strive to eliminate the gonococci. 

We should look upon the inflammation as Nature's re- 
action, which should not be interfered with. We should 
not destroy the carriers of infection, because they generate 
substances which serve curative purposes. But recently 
we were taught to attribute to the leucocytes an inherent 
curative power tending towards self -limitation of infec- 
tious diseases. In being devoured by the microbes (pha- 
gocytosis), which cause their augmented appearance, they 
serve as destroyers and eliminators. It is not yet defi- 
nitely settled whether this is an active performance of the 
leucocytes, as Metschnikoff thinks it to be. In the mis- 
taken idea of inci^easing their numbers in the system and 
to fortify its resistance, speculative pharmacy has devised 
the administration of nucleines and nucloalbumins. 

Furthermore, it is significant in this connection to note 
the view of Drobny in Charkoff, and others, that the 
course of gonorrhea is dependent upon whether the gono- 
cocci are contained within the leucocj'tes or are outside of 
them. Treatment is alleged to be more promising when 
they are intracellular; when they are found outside of the 
cells, treatment should by no means be instituted. In 
this latter eveut it is held that the gonococci or their tox- 
ins have somehow impaired the power of the leucocytes 
to absorb or of being absorbed (failing phagocytosis). 



184 CHRONIC URETHRITIS 

We think it certainly worthy of consideration to dwell 
for a moment upon the manner in which other self-limited 
infectious diseases end in recovery. In typhoid, for 
instance, it is alleged, that the causative microbe gene- 
rates, as they all do, products of its metabolism. We 
may call them toxins or whatever else. These waste pro- 
ducts of microbial life are in turn deleterious to their gen- 
erators. Within a limited time, in our example, at the 
end of the fourth week, in cases which recover, the ac- 
cumulated microbial waste will make the soil — the blood, 
which at the same time has elaborated antagonizing sub- 
stances — uninhabitable to further microbic life. The ty- 
phoid bacillus has perished by its own toxins. 

Finger states, in his recent publication, that gonorrhea 
is capable of spontaneous recovery, and that he has seen 
many cases get well in clinical practice under bed -rest 
and diet. This means that Nature's reparatory endeavors 
were sufficient to accomplish a cure. But since gonorrhea 
will rarely be treated under hospital restraint, and the 
average ambulatory patient is exposed to all sorts of nox- 
ious influences, we must resort to therapy in order to has- 
ten matters. Finger recommends for the acute, purulent 
stage only antiseptics, such as Protargol and Largin; for 
the second, or muco- purulent stage, remedies which are 
bactericidal and astringent, such as Argentemin and ni- 
trate of silver (0.05 — 0.1:200.0), especially when the 
threads have diminished and the subacute stage has set 
in. For chronic gonorrhea, in order to combat the super- 
ficial infiltrations, nitrate of silver for the more recent 
affections, and sulphate of copper for the older lesions, as 
washings in diluted, and instillations in concentrated, 
solutions. For the deeper infiltrations mechanical means. 

After this, we hope pardonable, excursion, we return 
to the use of Protargol in chronic gonorrhea. Here it is 
that the use of astringents are indicated. In the acute 
stage the use of astringents was absolutely contra -indicated. 



TREATMENT OF CHRONIC GONORRHEA 18;") 

They cause a reflex contraction of the blood-vessels of the 
mucosa, and by so retarding the extravasation of pus -cor- 
puscles and pus -serum, they prevent the reactive inflam- 
mation which floats out the gonococcus. But in chronic 
gonorrhea the case is different; here the gonococcus exists 
in the deeper structures and in lesser numbers, and is 
probably attenuated in its virulency. The mucosa has be- 
come tolerant to its presence. In consequence of this 
latency and its enfeebled condition, it does not set up irri- 
tation enough to cause a discharge sufficient to carry this 
out. The gonococcus will therefore lie in the depth of 
the lacunas or Lattre's glands, or deeper yet in the con- 
nective tissue and cavernous bodies, or in the accessory 
genital glands, where it may have penetrated while the 
gonorrhea was in the acute stage. But its presence will, 
nevertheless, cause lesions of the mucosa in the form of 
erosions, granulations, and fissures. 

These superficial processes will be influenced in a most 
beneficial and curative way by the antiseptic astringents, 
such as nitrate of silver and sulphate of copper, in irriga- 
tions or instillation. Again, the continued presence of 
the gonococcus and its toxins will cause structural changes 
in the form of connective- tissue hyperplasia, causing peri- 
urethral infiltration with gradual impairment of the dilati- 
bility of the urethra. Thus the beginning of a stricture 
is established. When such deep structural changes have 
once taken place, no form of injection will be of any use, 
and we must resort to mechanical means, such as bougies 
and sounds. Generally speaking, the lesions of chronic 
gonorrhea will be treated by washings of nitrate of silver, 
or by instillation of nitrate of silver or sulphate of copper 
accordingly, and by sounds, especially when these lesions 
persist, or when peri -urethral infiltrations have established 
themselves. 

For applications to localized spots the urethroscope will 
prove indispensable. When chronic prostatitis and sem- 



186 CHRONIC URETHRITIS 

inal vesiculitis are present, massage of these glands must 
be exercised. The use of the silver albuminate salts in 
chronic gonorrhea is only of secondary importance. But 
we recommend them in subacute exacerbations, brought 
about by various indiscretions of the patients, as adjuvants. 
Here, usually, a greater sensitiveness of the urethra pre- 
vails, and a flushing with a one -half to one per cent solu- 
tion of Protargol will prove serviceable. In these chronic 
cases, therefore, we are in need of an astringent of caustic 
properties which the Protargol does not possess, but the 
nitrate of silver does.] 



CHAPTER XII 

NOTES ON URETHRAL ASEPSIS* 

[Aseptic methods are now employed in all branches of 
surgery. It is an outcome of the antiseptic method inaugu- 
rated by Lister, and means prevention of fermentation and 
putrefaction. When one uses such means as to make his 
instruments, hands, and field of operation sterile, i. e., free 
from microbes, he is understood to work aseptically. Hav- 
ing in this way succeeded in shutting out the microbes, 
there is then hardly any more need to use the germicidal 
chemical agents called antiseptics. Furthermore, we know 
that the urethra, with its delicate lining membrane, is apt 
to suffer in its integrity by the use of even very weak anti- 
septic solutions. Instead of preventing the development of 
microorganisms, such irritating solutions will, by destroy- 
ing the epithelium, open an avenue of entrance to all kinds 
of microbes. It is therefore of the greatest importance to 
perform all instrumentations of the urethra with surgical 
cleanliness; that is, in an aseptic and non- irritating way. 
While this is true of all branches of surgery, and is vividly 
and typically carried out by the general practitioner, 
especially in his obstetric practice, there is a great deal of 
deficiency of this method when the urethra is the object of 
treatment. Happily times have passed when the practi- 
tioner carried his catheter, a well-worn and dilapidated 
looking affair, in his coat pocket, using his saliva to lubri- 
cate it, after having cleaned it with his handkerchief. But 
even the otherwise progressive man will very often content 
himself with doing justice to his aseptic conscience by im- 

*By the Editor. 

(187) 



188 CHRONIC URETHRITIS 

mersing his catheter in a doubtful looking bowl of hot 
water, using the dust -laden family vaselin jar, and anoint- 
ing the instrument with his undisinfected fingers. 

The eminent importance of aseptic catheterism has only 
been recognized in the last few years. Guyon, Alberran, 
Kuttner, Posner, Frank and others have shown us that un- 
clean catheterism is by far the most frequent source of 
urethral infection. The whole success of a cure depends 
upon the use of instrumental and urethral asepsis. 

We do not think that it is possible to attain an absolute 
asepsis of the urethra in the same sense as the surgeon pro- 
vides an aseptic field, and attacks it with aseptic instru- 
ments. The genito- urinary surgeon may avail himself of 
the later desideratum, but he cannot fulfil entirely the first 
want. The healthy urethra is the seat of a very multiform 
microbic flora; some not pathogenic, some pathogenic, and 
others becoming so under favorable circumstances. Since 
we cannot, by reason of the peculiar sensibility and vul- 
nerability of the urethral mucosa, render it absolutely 
aseptic, we must strive to use weak antiseptics, such as 
will not cause any lesions of continuity. The asepsis of 
instruments is, therefore, the most vital point. Its pains- 
taking use has in a certain way to cover the imperfect 
asepsis of the urethra itself. 

In making an exploration of the urethra certain meas- 
ures must be observed, which may be summed up as pre- 
liminary and actual steps. 

Concerning the first we must make it a rule, before 
handling the parts to be treated, to wash our hands in hot 
water with soap and brush, afterward immersing them in 
an antiseptic solution of bichloride 1-1000. Small rec- 
tangular pieces of linen kept in a well -closed jar, and pre- 
viously treated with a 1-1000 bichloride solution, should be 
used to grasp the penis with the left hand. This latter 
measure serves at the same time as a protection to the 
physician's fingers. As a first step in the right direction, 



NOTES ON URETHRAL ASEPSIS 189 

the meatus must uow be disinfected by wiping it and the 
glans with cotton pledgets, soaked in a bichloride solution 
of 1-1000. As this solution, when left in contact too long 
with the tender skin of the glans and the sensitive mucous 
membrane of the urethral orifice, proves somewhat irri- 
tating, a five per cent solution of boric acid should be used 
afterward in the same way, also instilling a few drops of it 
into the orifice. Of course the patient has to void his urine 
before. The next step consists of disinfecting the urethra. 
There is a great difference of opinion whether the micro- 
organisms which inhabit even the normal urethra are capa- 
ble of infecting the bladder or the kidneys. It is certainly 
a good plan to irrigate the urethra with sterilized water or 
a four per cent boric acid solution before introducing the 
catheter or sound. But in our opinion it is not essentially 
necessary in cases where a non- infectious process is to be 
combated. It goes without saying, however, that flushing 
the urethra is of the utmost necessity when we have to deal 
with gonococcic or other microbial affections. Having 
thus rendered the parts surgically clean, we may now safely 
proceed to the second actual step of instrumentation. In 
this connection we have to take into consideration how to 
render our instruments aseptic. It would fall beyond the 
scope of these notes to dilate upon the value of different 
methods of sterilizing our instruments. Elastic instru- 
ments need another mode of procedure in this respect than 
metallic ones. As these short notes should serve only 
practical purposes, we will but mention that there are 
elaborate methods and costly appliances of fulfilling the 
most stringent rules of asepsis. But we will consider here 
only such appliances which can be had or improvised by 
every practitioner at a small cost, and serve the purpose in 
view just as well. 

To render elastic catheters and bougies aseptic, steam 
is the most serviceable method, and guarantees absolute 
sterilization. Kuttner has devised a very suitable appara- 



190 



CHRONIC URETHRITIS 



tus, Fig. 26, which carries the steam not only to the outer 
surface of the catheter, but through it also. It is certainly 
a very desirable one and, for the consulting room of the 
specialist, of great value. But we can use an ordinary fish 




Fig. 26. Kuttner's Steam- Sterilizer for Catheters. 
The illustration shows only the boiler, which is partly filled with water 
E, and rests on a cylindrical stand with burner (not shown above). E, small 
tube for the egress of steam, through which the steam reaches compartment 
K and escapes through G and B. But when, as in the illustration, the stopper 
is inserted, both openings being closed, the steam can take its way only through 
the holes L into and through the catheter F. The catheter F is so suspended 
that the steam must pass through it from above downward, escaping through 
its eye, and passing along the outside escapes by means of outlet D. 

kettle of smaller size, which will serve excellently this and 
several other purposes. In the [lower compartment we, r boil 
the metallic instruments, and in the upper the elastic ones 
are placed. 



NOTES ON URETHRAL ASEPSIS 191 

Bacteriological investigations have proved that the 
common pathogenic bacteria are killed by immersion in 
boiling water or in steam for from two to five minutes. 
Even the most tenacious of them, the spores of the an- 
thrax bacillus, dying in two to four minutes when so 
treated. By using one teaspoonful of carbonate of soda 
to the quart of water, rusting of the instruments is pre- 
vented. If we now allow fifteen minutes for boiling, 
steam enough will have developed, which, being under 
quite a tension, will circulate through the catheter lumen, 
rendering it sterile. 

Posner, who entertains very doubtful views about our 
ability to absolutely render elastic instruments aseptic, 
recommends a yet simpler method of disinfection. Met- 
allic instruments, as we know, are easily dealt with, and 
boiling them for two minutes, or a little over, completely 
sterilizes them. But with elastic instruments, like the 
Nelaton catheter and the woven ones, the matter is differ- 
ent. In an emergency, when the eventual damage to one's 
instruments is of no consequence, boiling of the elastic 
instruments will, of course, render them aseptic. They 
stand it a few times, but will soon lose their coating, be- 
come fissured, and useless. The nearest approach towards 
rendering them aseptic is, according to Posner, to put 
them in a five per cent solution of carbolic acid for, say, 
ten minutes, after having previously cleansed them thor- 
oughly, or in a 1-1000 bichloride solution for a shorter 
time; then flush the catheters through with a syringe, 
using the same solutions and then with boiled water. To 
prevent reinfection the instruments should be wiped off 
with bichloride gauze and then lubricated with sterilized 
glycerin, or with boric glycerin of the following compo- 
sition: Boric acid, 9 parts; glycerin, 63 parts; distilled 
water, 75 parts. Glycerin has the advantage, besides its 
germicidal power, of being soluble in water, and hence 
permitting an easier cleansing of the instruments. It is 



192 



CHRONIC URETHRITIS 



best to use catheters, in which the space between the eye 
and the distal end — the so-called "dead space," which 
forms a pouch, where bacteria thrive and abound — is abol- 
ished and filled out. This has the other 
advantage of giving the catheter a firm end, 
rendering it easier dirigible. 

It may suffice to mention other methods 
of disinfection now in vogue. Besides the 
solutions already mentioned, some make use 
of chemicals in vapor form, sulphurous acid 
or mercurial vapor, which, however, hardly 
possess any disinfecting powers utilizable for 
our purpose. The most modern is formalin 
vapor. It is a useful antiseptic, but it has 
its disadvantages in catheter sterilization. 
It takes twenty-four and more hours to get 
the desired effect, the fumes of the drug cor- 
rode metallic instruments, and elastic ones 
soon become soft, sticky, and exfoliating. 
Besides, the coating of formalin vapor which 
settles on the surface of the instruments, 
being irritating to the mucous membrane of 
the urethra, must be washed off before in- 
troduction. 

To sum up, the simplest, cheapest, and 
most effective method of rendering metallic 
urethral instruments aseptic is boiling them 
in a one per cent soda solution for not less 
than two minutes. 

Elastic instruments will bear the steam 
very well, and may be rendered aseptic by 
using the household contrivance mentioned 
on p. 190. 

To those who prefer a yet simpler method 
the use of the antiseptic solutions mentioned 



Syringe, 



Fig. 27 
with Glass Bar- 
rel and Hard- 

T?T1RRFR At^TTTST 1 * 

gr E Sm H e°s Lwng8 ° before will recommend itself. 



NOTES ON URETHRAL ASEPSIS 193 

It is, of course, understood that the handling of the 
instruments, after their having become aseptic, must be 
such as not to jeopardize the results attained. It is, 
therefore, a good plan to have a few towels, previously 
rendered aseptic by steaming, or by boiling them in a 
three per cent solution of carbolic acid, or in a 1-1000 of 
bichloride, to spread the instruments upon. 

A few words concerning the accessory instruments: 
The irrigator should be of glass. When bichloride (very 
rarely) or nitrate of silver solutions are used for irriga- 
tions, they render it aseptic by their own germicidal pow- 
ers. When other solutions, such as boric acid or the per- 
manganate, are employed, which in themselves possess a 
weaker germicidal power, then it is advisable to boil or 
let a stream of hot water flow through it previously. 

Syringes, if of the modern sterilizable pattern, are 
easily rendered aseptic by boiling. The compound ones, 
made of a glass barrel and hard rubber adjustment, can- 
not be boiled. (Fig. 27.) They are rendered aseptic by 
putting them into a 1-1000 bichloride solution for not less 
than fifteen minutes, and, if possible, for one hour, and 
drawing the barrel full of the same liquid. Before using 
they should be flushed through with boiling water. 

It is obvious that for the use of bichloride and nitrate 
of silver solutions the glass -nozzled irrigator, or the hard 
rubber syringe with a soft rubber tip have to be em- 
ployed . 

When all these steps are carried out faithfully, and a 
certain methodical manner of employing them is adhered 
to, we have attained a degree of surgical asepsis which, 
if not ideal, is at least the very best we can do in the 
present state of cur bacteriological knowledge. There 
are, we know, some intraneous, hematogenic sources of 
infection of the genito- urinary apparatus, but they are 
rare in comparison w r ith the extraneous sources, and cause 
infection as a result of unclean catheterism. Aseptic cath- 

M 



194 CHRONIC URETHRITIS 

eterization is not only a possibility, but a necessity. We 
must not only strive to perform it in an aseptic way, but 
we must regard it as a law, as an ironclad rnle, the omis- 
sion of which is on a par with criminal negligence, and as 
such to be avoided by every conscientious physician.] 



CHAPTER XIII 

MECHANICAL TREATMENT 
INSTRUMENTS 

I. Bougies — Antrophores. — Whatever may be the 
action of the remedy employed, injections, instillations, and 
lavages are often insufficient to effect a cure. This treatment 
is, in a large number of instances, also inefficient. Thus 
we have been led empirically to employ a mechanical treat- 
ment. About twenty years ago elastic bougies began to be 
employed in rebellious cases, and their use has been per- 
sisted in to the present time. These bougies of large 
caliber were inserted into the urethra as far" as the bladder, 
and left in place for from ten to twenty minutes. They 
were reintroduced daily or once a week, gradually increas- 
ing the caliber. This treatment, combined with astringent 
injections, has given and still gives good results. If we 
have to deal with soft infiltrations, and if the caliber of the 
meatus is of sufficient capacity, we can readily understand 
that it is possible by the use of large bougies to cause 
slight tears in the infiltrations, and thus to provoke their 
absorption. 

Ultzmann, in cases of the firmer infiltrations, advised 
the use of increasing sizes of metallic sounds; these he in- 
troduced once or twice a week, increasing each time, if 
possible, the caliber by one number of the scale (i mm.). 
At the same time he employed astringent and caustic in- 
jections. Unfortunately the diameter of the meatus 
scarcely permitted passing number 25 or 26, and the 
method found here ^its limits imposed by Nature. Burck" 

(195) 



196 CHRONIC URETHRITIS 

hardt, to obviate these inconveniences, cut the meatus, and 
thus succeeded in passing number 30 or 32. The results 
which he obtained are naturally still better; but, unfor- 
tunately, this incision of the meatus and the introduction 
of these enormous sounds constituted quite a barbarous 
form of treatment. Furthermore, the bulb possessing 
normally a dilatability very much greater than that of the 
penile portion, left the problem not wholly solved, and the 
largest sounds became inadequate. 

[The question of cutting the meatus has been and is yet 
ventilated. The experienced Otis advises to cut every 
meatus in cases where the orifice is found so small as to 
cause retention of discharge, or oppose the introduction of 
instruments for definite diagnosis and treatment. Ultz- 
mann wants every meatus slit which does not admit at least 
a 27 F (=18 American size), while Nitze entirely discards 
meatotomy. We have witnessed him introduce large 
lithotriptors through orifices of 10 and 12 F., under infil- 
tration anesthesia, with ease. 

The objections against meatotomy that it impairs the 
force of the stream and sexual capacity are not valid. 
While the opening should be made wide enough to admit 
sounds 28 to 30 F (18 to 20 American scale), we should 
avoid dividing the orifice to such an extent as to cause 
ectropium of the lips almost simulating balanic hypo- 
spadias (Chettwood). The little operation is performed 
under local cocaine or eucaine anesthesia. A narrow 
bistoury is introduced, and the cut made alongside the 
floor of the urethra. A pair of sharp scissors will answer 
the same purpose. A strip of iodoform gauze is then in- 
troduced in the urethra, which serves both the purpose of 
haemostasis and of keeping the cleft open. Profuse hemor- 
rhages are rare, and can be controlled by a circular bandage. 
The caliber should be maintained by the introduction of 
short conical sounds.] 

Other authors have endeavored to employ bougies and 



MECHANICAL TREATMENT 197 

cauterizations simultaneously. For this purpose they in- 
troduced into the urethra sounds covered with nitrate of 
silver ointment (Unna, Casper, Flemmer). This pro- 
cedure which, although it seemed rational, did not produce 
the results expected of it; nearly all of the ointment was 
left in the region of the meatus if sounds of sufficient cali- 
ber to act by dilatation were used; if, on the other hand, 
small -caliber sounds are used, the ointment may reach all 
parts of the urethra, but will be without action upon the 
hard and deep infiltrations of the mucous membrane. The 
same objections may be made against the antrophores 
advocated by certain writers. In the majority of cases, 
when the urethritis is obstinate, it is so because deep infil- 
trations exist in the mucosa. All measures, then, which we 
have just enumerated remain without sufficient results. 

[The application of pressure in union with antiseptic 
astringents did not prove as effectual as it promised to be. 
Even Casper's grooved sounds could not entirely obviate 
the drawbacks pointed out before. The warmth of the 
urethra will solve out the ointment and expose the entire 
urethral mucous membrane to the irritating drug. It 
is, therefore, better to dissociate pressure from the drug 
application, and use sounds and instillation in their sepa- 
rate ways. We may use the sound and then instillation at 
one sitting. If there is great irritation present, it is bet- 
ter to perform each application on separate days.] 

II. Dilators. — With the aim of reaching such lesions, 
Otis (New York) and Oberlander (Dresden) successively 
or simultaneously constructed their dilators. These dila- 
tors are absolutely different from the old divulsors em- 
ployed by different authors in the cure of strictures. Fol- 
lowing out the features aimed at in the construction of 
these instruments, their caliber was quite small; they were 
indeed intended for very tight strictures, in which dila- 
tation was to act with great force; in this way the 
caliber of the canal was rapidly brought up to a point at 



J 98 



CHRONIC URETHRITIS 



which free micturition was made possible. Once this re- 
sult obtained, the process stopped there. Our dilatations 
at the present time go, as we know, much farther; thus 
the old style of instrument has become absolute^ insuffi- 
cient. Besides, the method formerly employed had de- 
cided inconveniences; the dilatation was violent and 
brusque; it was a veritable divulsion "which caused deep 
tears in the tissue of the stricture, over which there flowed 
at once an infected urine. From this there arose numer- 
ous accidents, which explain the discredit into which the 
method has fallen. We shall see that the action of dila- 
tors of the present daj r is an entirely different matter. 
Besides, in covering them over with a rubber hood we are 




Pig. 28. Oberlaender's Straight Dilator for Anterior Urethra. 



protected against little accidents of a very disagreeable 
nature, such as pinching the membrane. Their antiseptic 
care is, moreover, rendered very easy. 

The Otis Dilator (dilating urethrotome) is a dilator 
having two branches, separating by the action of a screw. 
The upper branch carries a small hidden knife, which can 
be made to spring forth at will in points w r here the dilata- 
tion meets with resistance, and where, consequently, mu- 
cous infiltrations exist. Nothing proves, unfortunately, 
that the blade does not penetrate healthy tissues of the 
urethral wall, and thus add an additional lesion to the 
older ones we are seeking to cure. 

The Dilators of Ober lander (1887) are made on the 
Otis model. Oberlauder and, afterward, Kollmann have 
since greatly improved these instruments, which are the 
only ones employed to-day. These dilators are composed 
essentially of two steel branches, applied one against the 



MECHANICAL TREATMENT 



199 



other; when closed, they have the form of a metallic sound 
and a caliber corresponding to number 15 of the Charriere 
scale. These branches, by an arrangement of hinges and 
a screw, may be separated at will, the distance from each 




Fig. 29. Oberlaender's Curved Dilator, mainly for Dilatation of 
the Bulbous Portion. 

other is exactly measured by a dial near the handle of 
the instrument. In this way the caliber of the sound 
which it represents increases little by little over a certain 
extent of its length, according to the extent of dilatation 
which we wish to obtain at this point. The details are 
better given by the accompanying illustration of the in- 
strument than by any description we might attempt. At 
the present day we employ the following instruments: 

1. A short dilator (16 cent.), which is straight, and 
whose extremity is slightly curved to represent the form 
of the penile urethra, together with the beginning of the 
bulbar region (Fig. 28). When this instrument is opened 




Fig. ho. Oberlaender's Benique-Cirve Dilator. 



its caliber corresponds to that of the canal; that is to say 
it is much wider at the bottom than at the part which cor- 
responds with the meatus. We may, by introducing this 
instrument, dilate all parts of the anterior urethra as far 
as the bulb. 



200 CHRONIC URETHRITIS 

2. A longer dilator (21 cent.) with branches more 
parallel and with an extremity more curved, having the 
form of Ultzmann's sounds (Fig. 29). When the instru- 
ment is in place, the heel of the curve, the point where the 
dilatation is the most pronounced, rests exactly in the cul- 
de-sac of the bulb. The instrument is thus well suited 
for infiltrations in this region. 

3. A dilator having the form of the Benique sound 
(Fig. 30) and dilating only in the part corresponding to 
the posterior urethra. It is employed only for this region. 

Oberlander has constructed still other types of dilators. 
Those we have described are the most generally em- 
ployed. 

Kolhnann has slightly modified these instruments in 
giving to them four branches, so as to exert a more uni- 
form action upon the whole circumference of the urethra. 
He employs, notably, a straight dilator (Fig. 31) for the 
penile region, a curved dilator for the bulb (Fig. 32), and 
a Benique dilator (Fig. 33) for the posterior region. All 
of these instruments are constructed of excellent steel, 
that will not bend, so as to exert a uniform action and pre- 
serve exactly the form and the degree of distention which 
has been given them. The flexible branches of the old 
dilators gave way too readily at the points where the re- 
sistance in the urethral walls was the greatest; that is to 
say at the very points where scleroses existed; or, in other 
words, precisely where their action should be the most 
energetic. In the instruments of Oberlander, on the con- 
trary, the branches are very rigid; the dilatation is pro- 
duced by their passage and by a play of the joints, which 
increases still more the resistance. The dilators require 
to be kept carefully cleansed by reason of the delicacy of 
their function. It is necessary, every day after they have 
been in use, to expand the instrument completely and 
wipe it carefully by means of a dry cloth; the hinges are 
to be principally looked after, and care must be exercised 



202 CHRONIC URETHRITIS 

not to allow them to become rusty. When the instrument 
is thus well rubbed, it is to be coated with a thin layer of 
petroleum by means of a small brush, and then wiped 
again, so as to remove all excess of fatty matter. 

These details are not unnecessary-, because the instru- 
ment, when well cared for, can be used for a long time 
without requiring any repairs, while it gets out of order 
at once if it is not properly looked after. 

The rubber slip cover (Fig. 34), which one should never 
neglect to place over the instrument each time a dilatation 
is to be carried out, fills a double function ; it prevents the 
mucous membrane from becoming pinched between the 
branches of the instrument when the latter is closed, and 
from being dragged upon when the instrument is with- 
drawn; in the second place it alone comes into contact 
with the walls of the urethra and, being capable of being 
kept aseptic, renders very great service from this point 
of view. After each dilatation we must at once remove 
the cap covering the dilator,, clean it carefully, wash it in 
some antiseptic solution, boil it or sterilize it, as one may 
prefer, and keep it aseptic until it is to be used again. 

[In order to combine dilatation with irrigation, without 
change of instruments, Kollmann, of Leipsic, has recently 
devised so-called irrigating dilators. Fig. 35 represents 
one for the anterior; Fig. 36 another for the posterior 
urethra. Lohnstein and Scharff had previously used in- 
struments on this principle, but Kollmann improved them 
by making the dilating branches stronger and by rounding 
their edges, in order to avoid pinching of the mucous mem- 
brane when closed for withdrawal. The use of a rubber 
hood is therefore here unnecessary. Below the dial near 
the handle are two projecting nipples for the attachment of 
rubber tubes. Each leads to a. tube enclosed in the hollow 
axis of the instrument. One tube opening within the first 
third of the instrument, the other through four little holes 
at the end of the axis, producing jets in a retrograde direc- 



204 CHRONIC URETHRITIS 

tion. The instrument is well lubricated with glycerin and, 
like all dilators, is introduced closed. When in place we 
commence dilatation, one or two millimeters at a time, as 
indicated by the hand on the dial. Irrigation with the 
large hand syringe is then made, first through one, then 
through the other rubber tube. The fluid used is a three 
per cent very warm boric solution, at 100 to 110° F. It 
seems that the heat of the injection exerts a softening and 
soothing effect on the infiltrations, which permits a higher 
grade of dilatation afterwards. Besides, the contents of 
plugged urethral glands or crypts are more easily floated 
out when the washing is performed under expansion. 
Eventually the necessary instillations are performed in the 
usual way, after removal of the instrument. 

Kollmann's four-branched dilators have, when closed, a 
diameter of number 20 F. (13 American scale). Those of 
the irrigating dilators number 25 F. (17 American scale). 
The shaft above the dilating parts number 16 F. (10 
American scale). In cases of congenital or acquired 
narrowness of the meatus, we will use short, conical, 
metallic sounds preparatory to the use of the dilators. 
Cutting of the meatus will, of course, be necessary, where 
the orifice does not admit a 16 F. without much discomfort. 
The advantages of these dilators consist, therefore, in 
enabling us to perform dilatation up to 30 and 40 F. (20 to 
28 American scale) , even in such urethras where the orifices 
would not admit higher numbers than 16 F. without 
painful distension. In using dilatation we must bear in 
mind that the aim of dilatation is different, according to 
whether we have to treat an established stricture or chronic 
gonorrheal infiltrations. In stricture we desire to attain 
restoration of the caliber of the canal by mechanical pres- 
sure and by the dynamic action of the bougie, sound, or 
dilator. In chronic gonorrhea our object is to influence the 
infiltrated tissues and promote absorption by the same 
means (pressure), but we also strive to empty glands and 



MECHANICAL TREATMENT 205 

their clogged ducts, the crypts and other follicular depres- 
sions containing pent-up material. The gradually distend- 
ing branches of the dilators will squeeze them out more 
readily than metallic sounds with unchangeable diameter 
would do. Dilators possess, furthermore, the decided ad- 
vantage of exercising gradual distension onlj' on such parts 
of the urethra as are in need of it. They expand in a man- 
ner corresponding with the anatomical conditions. The 
anterior urethra is shaped like a cone, widest toward the 
sinus bulbi, and gradually narrowing toward the meatus. 
The bulbous portion is, therefore, the most dilatable, while 
those parts of the anterior urethra situated in front of the 
bulb are successively less dilatable. (Fig. 2, p. 11). The 
anterior dilator is therefore constructed in such a way as to 
distend the bulb most, and the other parts toward the 
meatus less. Its use is confined to the parts from the 
meatus to the bulb. The posterior dilators are also con- 
structed on the same principle, with the greatest expansion 
toward the prostate and tapering toward the pendulous 
urethra. The posterior urethra, as we know, consists of the 
membranous and prostatic parts. If we wish to dilate the 
former, with the patient in a horizontal position, the shaft 
of the instrument must stand almost vertical. When the 
prostatic part is to be dilated the shaft must form an angle 
of 45° with the horizon. We never use a lubricant directly 
on the instrument, as merely dipping the dilator in talcum 
allows the rubber cover to be drawn over it. As a lubricant 
to this glycerin is used. 

Irrigating dilators, which are used without rubber hoods 
and metallic sounds, are best drawn through the flame of an 
alcohol lamp to make them aseptic, or they may be boiled 
and sterilized. Kollmann has devised a steam sterilizer 
for this purpose, similar to his cystoscope sterilizer, which, 
though very convenient, is not absolutely indispensable. 
Fig. 37, with a slight modification in its funnel, can be 
used for dilators also. We prefer keeping them in a jar 



206 



CHRONIC URETHRITIS 



filled with absolute alcohol. Before use they are wiped off 
with sterilized gauze. In being staunch advocates of the 
dilators, we do not think of discarding metallic sounds. 
A closed dilator of 16 or 25 F. is actually nothing else but 




Fig. 37. Kollmann's Cystocope Sterilizer. 



a sound of the same caliber. The difference sets in when 
dilatation begins. Where the meatus takes a 26 F. (15 
American) , we will use bougies or metallic sounds up to that 
number. As higher numbers would not be admitted, we 
must of necessity use dilators, whose circumference when 
closed is 20 F. An advantage of dilators over sounds is 
that we do not need to change instruments when the next 



MECHANICAL TREATMENT 207 

higher number is desired. The main contra -indication for 
the use of both are the presence of gonococci, acute ex- 
acerbations, and the presence of complications. We are 
in the habit of washing the urethra with the large hand 
syringe after every instrumentation with a three per cent 
boric acid solution, or with permanganate, 1 in 4000; or 
with nitrate of silver, 1 in 2000, according to the indica- 
tions present.] 

III. General Rules of the Method of Dilatation. 
— Operative Procedure. — This is how we proceed in a 
seance of dilatation: It goes without saying that one 
should never use the least violence. We must also strive, 
in so far as it is possible, to avoid giving pain. Thus we 
may render the urethra nou- sensitive from the start by 
applying cocaine (injection of four or five grains of a solu- 
tion of cocaine or of eucaine, in strength of 1 in 30, during 
five or six minutes) ; the patient will cany out, for a few 
minutes, gentle stroking along the canal so as to distribute 
the injection throughout the whole urethra. The closed 
dilator will then be covered with borated glycerin [or tal- 
cum powder,] and ensheathed in its rubber covering, which 
should be smoothly applied and free from folds. This be- 
ing done, the external surface of the rubber cap is smeared 
in its turn with glycerin or with neutral soap prepared 
after Guyon's formula. 

[This is a soap -glycerin salve of the following com- 
position: 

ly Pulveris saponis glyeerini. 

Aquae aa 30.0 

Ac. Cavbol eryst 1.0 

This soap must be of neutral reaction because an excess 
of alkali would irritate the mucosa. To avoid this irrita- 
tion Krauss has devised a lubricant, the basis of which is 
gum tragacanth. 

Iy Gummi Tragacantha*. 2.50 

Glyeerini ]0.0 

Aq. Carbolis at. (3%) 90.0 



208 CHRONIC URETHRITIS 

The advantage of this salve lubricant is that it does not 
contain fat which corrodes the catheter by dissolving its 
varnish. Another reliable domestic preparation called 
"Lubrichondrin " is also very useful. The catheter, in 
our case the rubber hood, can readily be washed, as the 
ingredients are easity soluble in water, and the salve 
remains aseptic for an indefinite period. These rubber 
hoods or caps are best kept in sterilized test-tubes plugged 
with cotton, after having been boiled or put in bichloride 
solution, 1 in 1000.] 

The instrument is then introduced in the same way as 
though it were a sound of the same form; once in place, the 
dilatation is begun by slowly turning the screw, which gov- 
erns the separation of the branches. In this way a degree 
of dilatation is produced, which gives the patient a slight 
sensation of tension and pricking. A pause is made suf- 
ficiently long for this disagreeable sensation to disappear; 
the dilatation is then begun again until the feeling reap- 
pears. In this way the desired degree of stretching is 
reached. We shall see, later on, how this degree of dilata- 
tion is exactly determined for each case. The instrument 
is allowed to remain in place for a few minutes and, after 
having been unscrewed, it is gently withdrawn. The first 
dilatation in a patient requires a certain amount of caution. 
If we have to deal with a stricture in which we succeed in 
passing the dilator, entirely closed and covered with its 
sheath, corresponding to number 16 Charriere for the first 
time, we should not go beyond 18 or 20. But in the ma- 
jority of cases the canal will have been previously examined 
by the urethroscope; it will then admit at least a number 
23, and the first dilatation w T ill go up to numbers 25 or 30, 
according to the pain complained of by the patient, and the 
importance of the lesions observed. 

For the subsequent sittings, we should still observe 
with attention the sensations experienced by the patient. 
As soon as he feels pain we should pause; at the end of a 



MECHANICAL TREATMENT 209 

certain time, the pain having disappeared, we begin dilat- 
ing again, and this will be continued up to the degree 
wished for. If the pain is severe and persistent, we should 
stop, whatever may be the number we have reached. 

The seances are held on an average of every ten or fif- 
teen days. Such are the general indications. We will 
study the detail of the method in the succeeding chapters. 
The advantages of this process of dilatation are evident. 
It is only necessary for one to have employed progressive 
dilatation by means of sounds in order to appreciate at once 
the difference on trying the dilators. The use of dilators 
permits one to localize, in a way, the mechanical action in 
the affected region, to measure accurately the force ex- 
erted, to graduate it at will without having constantly to 
introduce new instruments, and to spare the meatus, the 
most sensitive part, and the one most ill-treated by other 
methods. Besides, it offers all the necessary guarantees 
of perfect asepsis. 

To be sure, it may happen that one will meet with dis- 
agreeable situations if the requisite dexterity and neces- 
sary experience have not been acquired, and especially if 
one does not govern himself scrupulously by the rules of 
treatment. But we will call attention to the fact that all 
surgical procedures are open to the same inconveniences, 
and that, besides, the use of bougies and sounds have pro- 
voked, and still do provoke, more accidents than dilators 
have ever done. 

Conira-indications. — There exist some contra -indica- 
tions to the use of these appliances. They can scarcely be 
employed except after the acute period of urethritis has 
come to an end, and especially when the complications, which 
have perhaps arisen, have subsided or else passed into the 
chronic form. It is especially so in cases of posterior 
urethritis. If this posterior urethritis has been accompa- 
nied by epididymitis, prostatitis, etc., the greatest caution 
will be necessary. The acute phenomena should then have 



210 CHRONIC URETHRITIS 

completely disappeared for at least a period of fifteen days 
before we can dream of resorting to dilatation. 

The contra-indication is absolute if other affections ex- 
ist upon which dilatation might have a dangerous action, 
and notably in the presence of urinary tuberculosis; in the 
latter case even when its existence is not absolutely certain. 

Preliminary Precautions. — Certain precautions are in- 
dispensable before dilatation. Oberlander recommends 
that it should never be undertaken in the fasting state for 
fear of syncope. In very sensitive individuals we should 
gradually familiarize the canal with the contact of instru- 
ments, and abstain from all painful maneuvers during the 
early sittings. Once the operations have become familiar 
to the patient, we may act more energetically. We must 
also be careful to have the patient urinate immediately be- 
fore operation, so that afterwards he can retain the urine 
as long as possible. He will thus avoid the pain which 
might accompany the first act of urination, when the time 
which has elapsed after the operation has not been suffi- 
ciently long. If we remember to warn the patient, this 
pain, which is, by the way, quite insignificant after two 
or three hours, presents scarcely any inconveniences. 

Hemorrhages. — With these precautions, and if we act 
prudently, there is no fear that dilatation will be followed 
by accidents of any gravity. It happens quite often, how- 
ever, that it brings about a slight hemorrhage. We know 
that the dilator must cause slight tears in the infiltrated 
tissues, which become the starting point of a process of 
resorption. These tears are generally subepithelial, and 
do not make their presence known by any symptom. But 
it may happen, in eases in which the infiltration is very 
hard and of long standing, that they spread out more 
than we would have wished, and give rise to a quite con- 
siderable hemorrhage. Scarcely is the dilator withdrawn 
from the canal before we see a flow of blood or a hemor- 
rhage appear, which is very slight at this moment, and in- 



MECHANICAL TREATMENT 211 

creases materially after the first urination, so as to cause 
the patient great anxiety. 

In general, the flow of blood, when not considerable, 
stops spontaneously in a few minutes. If it persists, or 
is abundant, we can arrest it immediately by exerting com- 
pression upon the urethra. The patient will, for example, 
compress the canal gently by seizing the penis in the 
hand; after a few minutes the bleeding stops. If it be- 
gins again after urination the same maneuver is to be re- 
peated. We may also use a small linen bandage of one 
or two centimeters in width, which is rolled around the 
penis immediately behind the glans. This band is bound 
on tightly enough to arrest the bleeding. It does not pre- 
vent urination, and may be worn by the patient until the 
hemorrhage has ceased. In making a urethroscopic ex- 
amination after a seance of dilatation, we often see the 
canal present small longitudinal fissures or tears of varia- 
ble dimensions situated, by preference, on the inferior 
wall. These tears should be entirely cicatrized before di- 
latation is begun again, otherwise it will only tend to open 
them still more. 

The discharge is generally increased after each opera- 
tion. This is observed especially in the soft infiltration, 
in the transition forms passing into hard infiltration, and 
in the glandular forms; when the infiltration is very dense 
and constitutes what has been called soft strictures, this 
increase in the discharge is constant. When the dilata- 
tion has been overdone, a veritable acute recurrence with 
abundant purulent discharge may be produced; but this is 
the result of a faulty technique, which we must always 
strive to avoid. 

We must be cautious when it is a question of a long- 
standing affection which still suppurates abundantly. 
There exists then, in fact, around the old fibrous infiltra- 
tions, very extensive foci of soft infiltration; dilatation is, 
in these cases, always followed by an abundant suppura- 



212 CHRONIC URETHRITIS 

tion, due to the purulent breaking down of the infiltration 
tissue. This symptom disappears at the end of eight to 
fifteen days, but we can not undertake new dilatations 
before having obtained the sough t-f or improvement, or at 
least before the discharge has come back to the condition 
it was in before. The situation, however, is gradually 
improved, and the subsequent dilatations no longer give 
rise to other than a feeble and gradually diminishing 
reaction. 

Dilatation acts, on the contrary, in quite a different way 
in the dry and hard forms. The discharge, if any still 
exists, disappears after each seance, not to reappear for 
ten or fifteen days. At the same time the filaments, which 
are at first large and heavy, become smaller and smaller 
and gradually disappear. It is altogether exceptional after 
a seance of dilatation to have patients show signs of 
urinary fever. Such attacks are only encountered in run- 
down subjects or those whose upper urinary passages are 
affected. In such cases, however, the least manipulation 
in the urethra may occasion the same inconvenience, and 
we must take all possible precaution to avoid fever. The 
administration of antipyrin or of quinin beforehand, the 
use of saline purgatives, careful disinfection of the urethra, 
very complete cocainization, slow dilatation of short dura- 
tion, followed by rest in bed for several hours. 

[In patients where we have reason to expect febrile 
attacks after instrumentation, it is advisable to administer 
salol, 10 grains t. i. d., or better 3-et, urotropin, 8 grains 
t. i. d., as a preventive. In case of suppression of urine, 
besides urotropin, copious draughts of diuretic mineral 
water should be administered. It is a good plan to induce 
profuse perspiration to unburden the impaired kidney 
action. It is essential to wash the urethra with a four per 
cent boric solution before and after instrumentation.] 

As the patient's condition improves, there will be 
a gradual diminution and disappearance of all febrile 



MECHANICAL TREATMENT 213 

tendency, but the greatest caution will nevertheless be 
always in order. 

Mode of Action. — How does dilatation work, and what 
influence does it exert upon urethral lesions? To make a 
just estimate of this point we must proceed with a urethro- 
scopic examination immediately after the operation. We 
perceive then small, longitudinal fissures, a few milli- 
meters in length, covered with coagulated blood. These 
tears are situated wholly in the middle of the zones of in- 
filtration, and by preference in the neighborhood of the 
diseased glauds, whose excretory ducts they often traverse. 
They are never found in regions where the mucous mem- 
brane is normal. They are at times subepithelial, and 
extend into the mucosa. They cicatrize after a few days, 
and no further trace of them is found. From these fissures 
starts the process of resorption which should lead to a cure 
of the chronic lesions, and we can readily show that it is in 
their immediate neighborhood that the phenomena which 
mark the first stages of cure begin, and which we have 
described elsewhere. 

IV. Special Rules op the Method op Dilatation. 
— Let us now take up, one by one, the various forms of 
chronic urethritis and its treatment. 

Anterior Urethritis.— Soft Infiltration.— This form 
of chronic urethritis, usually encountered three or four 
months after the beginning of the infection, is that which 
is cured the most readily and the quickest. Here the 
nitrate of silver in washings (2 to 1 in 1,000) or in instil- 
lations (1 to 2 or 3 per cent) gives excellent results, and 
usually suffices to bring about complete cure. When the 
gonorrhea has spread to the posterior urethra and has there 
left traces, which often happens at this period, we must 
extend the silver washings (0.25 to 1 in 1,000) to this por- 
tion of the canal. Instillations in the posterior urethra 
(1 per cent) act more energetically perhaps, but are so 
painful that they should be avoided as much as possible. 



214 CHRONIC URETHRITIS 

We do not employ them. [We differ with the majority of 
the profession on this point.] 

The astringents and antiseptics are also found useful. 
The permanganate of potassium is especially convenient 
for the destruction of gonococci, which are still found at 
this period, and whose persistence exposes to recurrences. 
It is very useful, and sometimes rapidly dries up suppura- 
tion. Boric acid, corrosive sublimate, and the sulphate of 
zinc may also find a field of application, as well as internal 
remedies. Some will be prescribed to diminish discharge 
(astringents); others to rapidly asepticize the canal and 
diminish the danger of contagion (antiseptics). In gen- 
eral, we often employ the sulphate of zinc or the perman- 
ganate of potassium according to the case in question, 
the patient making for himself two or three injections 
daily. These injections are carried out at the same time 
as the nitrate of silver lavages, of which we have just 
spoken. 

[We had occasion to mention that we regard instilla- 
tion as especially adapted for the posterior urethra, and 
that in our experience the posterior urethra bears concen- 
trated astringents very well. As to w r ashings, boric acid in 
four per cent solutions will prove especially serviceable 
when used hot (104°) ; corrosive sublimate is rather rarely 
used, as it causes irritation in some urethras, even in a 
dilution of 1 in 10,000. The permanganate in solutions of 
1 in 4,000 to 1 in 6,000 we have found very useful in cases 
of persistent discharge. In weaker solutions, 1 in 6,000, 
it will allay the effects of a previous overstimulating treat- 
ment. It is a sound principle to conform our treatment 
to the condition of the mucosa, and to stop local treatment 
entirely for a while when irritative symptoms have set in. 
The salicylates or urotropin, with or without opiates, 
will tide us over until such subacute exacerbations have 
ceased. It will be then that the sedative action of thallin 
in solutions of three to twelve per cent, warmly recom- 



MECHANICAL TREATMENT 215 

mended byChettwood, will act beneficially, and at the same 
time preparatory to a more active treatment. The quan- 
tity injected should be from a half to two drams. It 
should be kept in dark bottles. Inasmuch as a subacute 
exacerbation might have caused gonococci to reappear, 
washings with a mild protargol solution (one -sixth to one- 
fourth per cent) will be in order. We are in the habit 
of advising the patient not to make any injection on the 
days when he has been treated by the physician. After 
the status quo has been established, washings with the 
nitrate of silver, the remedy par ' excellence in chronic 
urethritis, may be resumed.] 

When, in spite of treatment, cure is not rapid, or if we 
wish to accomplish it promptly and in a sure manner, we 
must resort to dilatation of the anterior urethra. 

In such cases we must act cautiously, and sittings must 
have long intervals between them. We begin by going up 
to numbers 25 or 30 at the first dilatation, and proceed 
very slowly in the subsequent sittings. Each dilatation 
will be followed by a decided increase in the amount of 
purulent secretion, and this recurrence of the discharge 
persists for two or three days. The fourth day a nitrate of 
silver lavage should be given: 1 in 1,000 in the anterior 
urethra; 0.25 or 0.50 in 1,000 in the posterior urethra if it 
is also invaded. If the reaction is violent, we must use 
boric acid for a wmile. The lavages with nitrate of silver 
are to be repeated once or twice with three or four days 
interval between them, and we cannot proceed with a 
second dilatation until complete disappearance of the reac- 
tional phenomena, consecutive to the first dilatation, has 
taken place. These reactional phenomena are the increase 
in the discharge, the pain on urination, and disagreeable 
sensation of tension caused by erections. We must also 
follow the course of the process by means of the urethro- 
scope. We will thus see, as the purulent secretion dimin- 
ishes, the redness and turgescence of the diseased zones 



216 CHRONIC URETHRITIS 

gradually disappear. The last traces to be seen will always 
be noted about the lacunas of Morgagni. As soon as the 
excretory ducts have taken on again their normal aspect, 
the mucous membrane should show a physiological color 
throughout its whole extent, and the folds should form in 
all parts as in a healthy membrane. The cure will then be 
probable; and we can be assured of it, if the normal feat- 
ures are still found three or four weeks after the patient 
has suspended all treatment. 

But the course of the pathological process is not always 
so simple. It often happens that the soft infiltration which 
we have recognized exists only on the surface of the mu- 
cous membrane, and that the deeper parts are the seat of 
an older hard infiltration. This latter becomes visible 
after disappearance of the symptoms of soft infiltration, 
and calls for an appropriate treatment at once. 

Finally, there are cases in which, despite all treatment, 
the soft infiltration possesses an invincible tendency to 
transformation into fibrous tissue. This peculiar course 
which, however, is but rarely observed, puts to test the 
sagacity of the physician. It is, however, useless to per- 
sist in an attempt to overcome this tendency; it is then 
better to suspend active measures and to persist with the 
palliative treatment exclusively, until such time as the 
disease, having gradually lost its acuteness, passes spon- 
taneously into the period of chronicity. The treatment 
then indicated will be that which is appropriate to the new 
form of urethritis thus constituted. 

Hard Infiltrations. — Once the parvicellular infiltration 
of the preceding period begins to undergo fibrous trans- 
formation, we pass to the second stage of the evolution of 
gonorrhoic lesions — hard infiltrations. To this stage be- 
long the slightest forms of periglandular infiltration, as 
well as the severest forms of stricture. There exists but one 
method of setting up a softening and resorption of the new- 
formed fibrous tissue: it is necessary to resort to dilatations. 



MECHANICAL TREATMENT 217 

Dilatation. — We have already enumerated the general 
rules of the method of dilatation and the contra- indica- 
tions to be met with. We should especially insist on these 
points: it is indispensable to act with caution and not to 
try to do too much at the first seance. If we have to deal 
with a stricture in which we introduce the dilator, for the 
first time we should not go beyond 18 or 20 F. If the canal 
has been previously examined with the urethroscope, we 
may go up to 25 or 30, inversely to the gravity of the 
lesions observed. 

Treatment Consecutive to Each Dilatation. — When the 
reactional phenomena consecutive to the dilatation are cor- 
rected, at the end of three or four days, for example, we 
should make a lavage of the urethra with a boric solution; 
then, two or three days later, a lavage with nitrate of 
silver; this silver washing should be repeated eveiy three or 
four days up to the time of making a new dilatation. At 
the same time we will continue, if there is necessity, the 
symptomatic treatment (injections of astringents in case of 
discharge, etc.). 

[We have stated elsewhere that it is a good plan to per- 
form washing with a four per cent boric solution after each 
dilatation. This is in accord with the accepted views of 
aseptic catheterization. It acts as a safeguard, if not 
entirely as a bactericide; and in a mechanical way by 
flushing out any microorganisms that may have been in- 
troduced inadvertedly despite aseptic precautions.] 

Subsequent Dilatations. — At the time of making a new 
dilatation, we should see that the anatomo-pathologic pro- 
cess set up by the preceding dilatation has completed its 
evolution, for it is this result which we must strive to 
reach. Too closely following one another, the dilatations 
unnecessarily irritate the canal; if there is too great an in- 
terval between, on the other hand, they have not sufficient 
effect to moderate the course of the morbid process and 
cause it to retrogress. From this point of view the recur- 



218 CHRONIC URETHRITIS 

rence of suppuration which one observes after each seance, 
may give quite exact indications; it results in fact from the 
purulent breaking down of infiltration tissue, and indicates, 
in consequence, the approximate intensity of the process of 
absorption. We must remark, however, that if the process 
is too violent it may give rise to a true inflammation capa- 
ble of extending to the peripheral tissues and then to the 
whole urethra. The discharge becomes in this case 
abundant, and a veritable recurrence has taken place. 
Such an accident is only possible if the rules of the method 
have been neglected, and the treatment has been badly 
applied; it can always be obviated by acting with caution 
and moderation. Should the discharge become notably in- 
creased after a seance, the following dilatation should be 
put off until this recurrence has subsided, and the urethro- 
scope examination has shown the termination of the pro- 
cess of consecutive resorption. Furthermore, at the fol- 
lowing seance the dilatation should be very slight, perhaps 
even not going beyond the number previously reached. If 
the reaction is, on the contrary, very slight or nil, we 
may w r ait a shorter time, and the following dilatation may 
be increased by two or three numbers. The dilations will 
be repeated at quite variable intervals; at a minimum after 
eight or ten days. 

A certain experience is indispensable to determine the 
exact time at which a new dilatation is indicated, and to 
what point it can be pushed. The following precepts 
will be useful in this connection: 

1. The seances of dilatation are generally followed by a 
slight pain at the time of urination. This pain disappears 
very rapidly, usually after several hours. Besides, the 
erections are accompanied by a disagreeable sensation of 
tension in the canal of the urethra; they persist often for 
several days and after their complete disappearance we 
must wait eight or ten days at least before proceeding 
with a new dilatation. ] 



MECHANICAL TREATMENT 219 

2. If the dilatation is followed by hemorrhage, Ave must 
wait at least fifteen days before repeating it. We should 
make no new dilatation nntil after the urethroscope has 
shown the cicatrization of the fissure. This cicatrization 
requires, at times, several weeks. 

3. The purulent secretion becomes, in general, more 
abundant after each seance. This recrudescence should 
first entirely cease, and the situation in this respect should 
be better than it was before, or at least approximately 
the same, before a new dilatation is permitted. 

4. If, on the contrary, the discharge has disappeared, 
or the urinary threads have diminished after the seance, 
we may proceed with a new dilatation if the purulent secre- 
tion has increased again. It is perfectly understood that 
the intervals between the dilatations should be of at least 
eight days. 

Such are the indications which may serve as a guide; 
but we should, nevertheless, always follow the course of 
the process by means of the urethroscope, and base con- 
clusions upon actual observations which one makes in 
this way. As we have just said, the discharge increases 
in the transition forms and in the glandular forms; but it 
is not generally the same in the dry forms, characterized 
by an abundant and dense connective -tissue hyperplasia. 
In these forms there is very often no visible discharge, 
and if any exists it may disappear completely after each 
dilatation, only to reappear after eight or ten days. How- 
ever, even in this case, we must not be led to use the di- 
lator at too frequent intervals. The course of the pro- 
cess of resorption is indeed not more rapid here than in 
the preceding forms; it is, on the contrary, slower and the 
treatment should often be an extremely prolonged one. 

Forcible Dilatations. — Whatever may be the form of 
urethritis we encounter, we must be on our guard against 
too violent dilatations at the outset of treatment. We 
must, on the contrary, act slowly and progressively. The 



220 CHRONIC URETHRITIS 

softer foci should be the first to pass into resolution. It 
is only later, when they have been completely absorbed, 
that we should resort to more energetic and more violent 
dilatations, capable of softening them, or of setting up an 
atrophic process in the hardest infiltrations. 

If, on the contrary, the dilatations are pushed too vig- 
orously at the outset, they may give rise to the formation of 
extensive fissures. In examining then the urethra through 
the endoscope, we will see persisting, alongside of the tear, 
small nodules of infiltration and glandular groups which 
will be influenced with difficulty later on, and to bring 
about whose resorption much pains and time is required. 

These forced dilatations may present another incon- 
venience; they set up at times a revival of the acute pro- 
cess which has seemed calmed — a recurrence. It is now 
that we see periurethral abscesses form. These are alto- 
gether exceptional accidents, which can always be avoided 
by adhering strictly to the rules laid down. 

It may happen, too, that a patient, in the course of 
treatment, is exposed to a new source of contamination, 
and that the latter sets up acute phenomena which appear 
or exacerbate immediately after a dilatation. The patient 
will naturally not admit the exposure {quivis syphiliticus 
[blennorrhagicus] mendax) , and will blame the treatment 
with having caused the recurrence; but he will be betrayed 
by the abundance of gonococci which are found in the 
discharge, and which a new infection alone can explain. 
This is an unfortunate accident, but happily of rare occur- 
rence, and one which we are powerless to prevent. The 
responsibility is incumbent upon the patient. 

[Reappearance of gonococci, few in numbers, may show 
up after such exacerbations, caused by over -excessive dila- 
tation. Such an event has not always the significance of 
relapse attributed to it by the patient. In a certain sense 
we may rather look upon it as a gain. Pent-up gonococci 
in the depth of the follicles might have been set free by the 



MECHANICAL TREATMENT 221 

action of the dilator, and the reactive purulent discharge 
floats them out. We will now proceed with the use of 
antiseptic astringents (permanganate, nitrate of silver in 
mild solutions) until the subacute exacerbation has sub- 
sided, and then resume dilatation.] 

Course and Treatment. — So long as the discharge has 
not disappeared, we will continue to perform, successively, 
dilatations and lavages, observing always with the urethro- 
scope the results obtained and the progress of the lesions. 
We thus gradually reach a number 40 dilatation, and even 
go beyond this if necessary. If we observe that there still 
remain infiltrations in the bulbar region which have not 
been absorbed, we must have recourse to the curved dilator 
whose action is especially exerted in this region. If they 
persist, on the contrary, in the very anterior portion of the 
penile region, we introduce the straight dilator onty half 
way, so as to place that portion of the instrument which 
dilates the most, opposite the diseased areas. It may also 
happen that a carefully made urethral examination per- 
mits neither of the discovery of infiltration, nor of the 
plaques of connective -tissue hyperplasia, and still there 
may remain a slight discharge. We must then search for 
the source of this secretion in the glands or the isolated 
lacunae in which the inflammation is shut in, and which 
cannot be reached by dilatation. This is a rare eventu- 
ality, but here the urethroscopic treatment steps again 
in its domain, because cure cannot take place except 
in going in and destroying the focus of suppuration 
in situ. 

Complementary Operations. — Local caustic applications 
by means of an endoscopic brush are absolutely ineffi- 
cacious. Kollmann has had constructed a small syringe 
armed with a long, slender cannula (Figs. 18 and 19, p. 77) 
through which he introduces a caustic injection into the 
diseased cavity. We may also make use of a small curette 
to^ explore the gland; but Oberlander recommends quite 



222 CHRONIC URETHRITIS 

particularly to destroy it by electrolysis. This little opera- 
tion is very simple, and is done in the following manner: 

A long steel needle (Fig. 16, p. 77), insulated almost to 
its extremity and having a blunt point, is pushed into the 
infiltration mass or into the glandular cavity; it is then 
attached to the negative pole of the galvanic battery. The 
positive electrode is applied upon the patient's thigh or 
even upon the penis, at the nearest point possible to the 
negative electrode. The current should not exceed two to 
two -and -a -half milliamperes. As soon as electrolysis has 
been effected, we see a little whitish froth emanate around 
the needle thrust into the area. The time of application 
does not exceed two or three minutes, but several weeks 
are required to obtain elimination of the eschar and secure 
cicatrization. During this whole time active treatment is 
to be suspended. Finally, it may happen that dilatation 
is powerless to soften the infiltrated nodules and the old 
cicatricial plaques surrounding the glandular masses, they 
being situated too deeply in the mucosa. This is an 
exceptional circumstance, but it may nevertheless present 
itself. Oberlander recommends to transsect these rebel- 
lious foci by means of a little blade (Fig. 15, p. 77) in- 
troduced through the urethroscope, or else to make a 
number of electrolytic punctures so as to set up a reaction. 
We may add that, in the great majority of instances, the 
method of dilatation, such as we have described it, always 
leads to cure. 

Duration of Treatment. — The length of treatment is 
extremely variable; it depends, first of all, on the nature 
and the extent of the lesions. Recent infiltrations, su- 
perficial and not very dense, will disappear readily un- 
der the influence of a few dilatations. The old connective- 
tissue masses, on the contrary, will offer great resistance 
to treatment; much perseverance will be required to trans- 
form them into inoffensive cicatricial tissue, incapable of 
setting up a recurrence.^ 



MECHANICAL TREATMENT 223 

Aside from these differences, which result from the 
gravity of the lesion, many other causes may intervene to 
prolong treatment. These are, first of all, causes often 
independent of the patient's will, and which do not permit 
him to restrict himself to an appropriate regimen or to fol- 
low out his treatment with a regularity which is indis- 
pensable. It is often, too, his intractableness; but most 
often there are individual characteristics which cause le- 
sions of benign appearance to resist for a long time an 
otherwise well conducted treatment. Recurrences are pro- 
duced by the slightest trifles, and the affection does not 
improve without our being able to clearly define the cause. 
This is especially noted in lymphatic subjects, or those af- 
fected with a tuberculous taint. We must, in these cases, 
act with the greatest circumspection and refrain from vio- 
lent maneuvers and from remedies of too great activity, 
which will only serve to make matters worse. During the 
whole course of treatment the patient will continue to use 
astringent injections as long as there is any discharge. 
When the discharge is dried up we will see, swimming in 
the urine, small purulent flakes, at first large and heavy, 
then more slender and light. As long as we can thus find 
traces of suppuration it will never be possible to guarantee 
that everything of an infectious character has disappeared, 
and thus that all danger of contagion is at an end. Even 
supposing that the most minute examinations, repeated 
several times, have not revealed the presence of the gono- 
coccus in the products of secretion, nothing proves that 
these organisms do not exist deeply seated in the areas 
still affected. They may, then, under the influence of this 
or another cause, constantly begin again to increase and 
reappear in the threads or in the discharge; the patient 
will then assume again the infectious character which he 
had appeared to lose. This hypothesis which we advance 
is verified only too often to leave any doubts about the 
matter. Patients declared cured and fit for marriage, after 



224 CHRONIC URETHRITIS 

an examination of the threads, which has been negative, 
present themselves again, complaining of inexplicable re- 
currences. We can only consider as cured those patients 
who no longer present the slightest trace of purulent secre- 
tion (discharge or urinary threads), [and neither gonococci 
nor pus- cocci, 1 and in whom the endoscopic examination of 
the most complete and careful kind has demonstrated the 
disappearance of the lesions previously observed. 

Posterior Urethritis. — The mucous membrane of 
the posterior region is thin, delicate, and almost entirely 
deprived of cavernous tissue; the lesions met with are also 
much less deeply seated and less severe than those of the 
anterior urethra. We find neither the large nodules of 
hard infiltration nor periglandular inflammatory masses; 
most often the blennorrhagic inflammation remains purely 
catarrhal and superficial. In many cases it suffices to 
employ a few washings of nitrate of silver (0.25 to 1 in 
1,000) to make these lesions disappear. The washings are 
repeated every two or three days; the cure is rapid, pro- 
vided the anterior canal has previously been cured, as we 
have already pointed out. 

If however, the posterior region is affected with hard 
induration, the nitrate of silver washings are not sufficient, 
and we must have recourse to dilatations. For dilatation 
of the posterior urethra, we must begin with complete 
anesthesia of the region by injecting a few grams of the 
usual solution of cocaine or of eucaine (1 in 30). We 
employ the Benique form of dilator. This is to be care- 
fully lubricated, and introduced into the canal according to 
the rules of catheterism with instruments of the same 
form. The introduction is very easily accomplished, but 
it may happen that the point of the instrument remains 
fixed in the region of the bulbar cul-de-sac ; this incon- 
venience is avoided by raising the dilator at the moment it 
traverses this region, and thus guiding the point along the 
upper wall of the canal. It is also by the same maneuver 



MECHANICAL TREATMENT 223 

that the instrument, once having- readied the prostatic 
region, will avoid the veruraontanum which is at times 
swollen and very sensitive, chiefly when the patient gives 
himself up to venereal excesses. As soon as the dilator 
has penetrated into the prostatic region, it no longer meets 
with obstacles, provided the canal is not constricted at this 
point by cicatrization of old prostatic abscesses. These 
strictures should then be dilated beforehand by means of 
metallic bougies. 

The first dilatation should not exceed numbers 25 or 30, 
especially if hard infiltrations exist. The operation is done 
with extreme ease and, so to speak, without any pain. The 
same rules are to be observed as those which we have indi- 
cated for dilatation of the anterior urethra. Furthermore, 
the severest lesions are always situated in the anterior 
region; therefore this region should be cared for first, and 
well dilated before we pass on to the posterior canal. 

The dilatations should be separated by an interval of 
fifteen days at least, during which nitrate of silver wash- 
ings are to be made (0.25 to 1 in 1,000) according to the 
sensitiveness of the patient, repeated every three or four 
days. 

Dilatation of the posterior urethra progresses very rap- 
idly, and we succeed in a few sittings in reaching number 
40. Besides, a posterior urethritis offers but little resist- 
ance to treatment once the anterior canal has been brought 
into a normal state. If, however, the affection is rebel- 
lious, it is undoubtedly because we have to do no longer 
with a simple urethritis, but that there exist complications 
or extensions of the gonorrhoic process to neighboring 
organs (prostate, seminal vesicles, etc.). The diagnosis 
should also be very precise in this regard, and a careful ex- 
ploration should indicate whether there exist foci of Pros- 
tatitis or Spermatocystitis capable of keeping up a per- 
petual gonorrhoic urethritis, or of becoming the point of 
departure for a recurrence. 



226 CHRONIC URETHRITIS 

The diagnosis and treatment of these complications are 
outside the scope of this work. [The Editor, trjdng to 
enhance the usefulness of this volume, has dwelt in the 
uext chapter ou the diagnosis of these conditions.] 



CHAPTER XIV 

PALPATION AND EXPRESSION OF COWPER'S, THE PROS- 
TATE, AND THE SEMINAL GLANDS* 

[Besides the different urinary tests, which convey valu- 
able information as to the origin of the threads, we possess 
a much more accurate way of determining whether Cow- 
per's glands, the prostate, or the seminal vesicles are in- 
volved, by using the method of palpation and expression of 
these organs. Physiologically, the terminal contractions of 
the muscular apparatus at the end of micturition, are in- 
tended to empty the bladder entirely, and also rid the effer- 
ent ducts of the accessory genital glands of their normally 
scanty secretions. But when the mucosa of the posterior 
urethra is affected, and the process of chronic inflammation 
has extended into these glands, changes occur in the texture 
of these organs. Some of the glandulae prostaticEe undergo 
cystic degeneration, or intumescation (prosatitis glandu- 
laris) with partial or entire occlusion of their ducts. In 
such a case the terminal contractions will not suffice, and we 
must look for other means to obtain the pent-up contents 
of these organs. We will therefore perform expression. 

Before going into details, it may not be amiss to venture 
a few words on the technique of expression. Most authors 
recommend the recumbent position. The patient lies on 
his back, with his knees flexed. The right index finger, 
protected with a well -lubricated rubber stall, is then intro- 
duced into the rectum, to a height varying with the posi- 
tion of the gland we wish to express; while the thumb 
rests on the anal muscles. The index finger in the rectum 
now performs, with its palmar surface, stroking motions 

* By the Editor. 

(227) 



228 CHRONIC URETHRITIS 

alongside the anterior wall of the rectum, while the thumb 
exteriorly makes passes toward the index finger. Mean- 
while the left hand placed on the symphisis pubis exerts a 
downward pressure on the pelvic viscera. 

We are somewhat partial to the performance of these 
evolutions in the knee -elbow posture of the patient. In 
this latter position we have succeeded in causing secretions 
to appear at the meatus, when the former posture proved 
ineffective. In bringing the patient into this position, we 
provide, it seems, natural means of emptying these glands. 
The intestines gravitate downward and forward, thus re- 
lieving the intra-abdominal pressure. The lowest part 
of the rectum by its fixation does not follow the intes- 
tines in their forward traction, but bulges toward the 
sacrum. This seemingly contradictory movement of the 
prostatic segment of the rectum in forming a convexity 
backward instead of following the bowels in their down- 
ward gravitation, we try to explain by the fact that the 
upper part of the sigmoid flexure follows the descending 
colon in its forward and downward movement, causing the 
sigmoid to form a bend at an obtuse angle with the rectum, 
which in turn causes the lower part of the rectum to form 
a convexity and to bulge toward the sacrum. Anyone can 
convince himself of this fact by introducing into the rectum 
a Sims' speculum while the patient is in the knee -elbow posi- 
tion. The rectum will be seen to follow the respiratory 
movements like a flap, up and down, but always, especially in 
its prostatic part, raised on a higher level and easier of access 
to the palpating finger than in the recumbent position. 
Besides, in performing expression, the secretions will, in 
this position, gravitate in a natural way through a pre- 
formed inclined plane toward the meatus. For the operator 
the whole procedure is an easier one; he can exert and 
grade the pressure with more leisure, the finger does not 
tire out as quickly as in stroking upward, and to the pa- 
tient the discomfort of the procedure is in no way aug- 



PALPATION AND EXPRESSION OF GLANDS 229 

niented. We have found that they can stand massage of 
the prostate — for curative purposes — much longer and better 
when in the knee -elbow position than in the recumbent 
one. We will, of course, avoid this position in older 
people, where arterio- sclerosis contra -indicates it. 

Expression of Cowper's Glands. — The anterior urethra 
is washed, without catheter, by the hand syringe and soft 
rubber nozzle (Figs. 5 and 27), with a warm four per cent 
boric acid solution. To this end the penis is grasped with 
the left hand, the index and thumb keep the orifice in 
contact with the nozzle which should fit tightly in the 
meatus. The fluid is now gently injected until the urethra 
commences to bulge. The thumb directing the piston 
downward now feels an obstacle caused by the contrac- 
tion of the compressor urethra? muscle. The fingers 
which hold the meatus against the nozzle now relax their 
grasp, and the fluid is allowed to escape. This maneuver 
is repeated until the fluid returns perfectly clear. The 
index finger of the right hand protected by a stall is now 
introduced to the height of about the first or second pha- 
lanx as the case may be. We stop at the lower border of 
the prostate, withdrawing the finger a little so as to avoid 
touching it at all. Pressure is now exerted by the index 
finger — with its volar side — in the manner of massaging 
movements downward and towards the operator. After 
doing this for a half to one minute we stop, allowing the 
thumb to propel the secretion towards the meatus by 
passing it strokingly forward alongside the membranous 
part of the urethra. We do not always have the satis- 
faction of seeing secretion appear at the orifice, even if 
the glands are diseased. The secretion may be too scanty. 
In such a case we may, if we care to, mop the deeper 
urethra through the endoscope and examine the secretion 
so obtained. However, as it is a rare event to find the 
glands of Cowper alone affected, we must not lay too 
much stress upon the negative result of our examination. 



230 CHRONIC URETHRITIS 

In almost all cases there will be an involvement of the 
prostate, which by its larger surface offers a greater ave- 
nue to all acute and chronic processes infesting the pos- 
terior urethra. 

Expression of the Prostate. — The digital manipulation 
of the prostate through the rectum, for diagnostic pur- 
poses, is almost identical with that carried out for curative 
reasons, known as massage of the prostate. It differs 
only in the degree of pressure and the duration of the 
manipulation. To make sure that we are obtaining the 
contents of the prostate only, we must eliminate all possi- 
ble sources of error. We will, therefore, after the patient 
has urinated, wash the anterior urethra and perform 
intra -vesical irrigation without catheter with a warm 
four per cent boric acid solution. This the patient 
voids into a graduate, and of the known quantity in- 
jected, about fifty grams are retained in his bladder. 
This serves as a residual fluid or vehicle, which can be 
voided in case expression should not yield enough dis- 
charge for examination. The washing is made in the 
manner mentioned above. But from the moment the 
thumb feels an obstacle to the further progress of the in- 
jected fluid caused by the contraction of the compressor 
urethrae muscle, we must change somewhat our technique 
of injection. 

Previously, when we have endeavored to cleanse only the 
anterior urethra, the compressor reacted against the influx 
in its physiologic way by contraction. As we were not 
desirous of was! ing the posterior urethra, we have, in the 
former instance, clayed to push the piston forward, at the 
same time releasing the grasp on the meatus. The fluid 
then returned anteriorly, as the compressor acted like a 
barrier between the anterior and posterior urethra. It is 
just this contraction of the compressor that we must now 
overcome in order to fill the bladder by hydrostatic pres- 
sure alone. Consequently we neither release our hold on 



PALPATION AND EXPRESSION OF GLANDS 231 

the meatus, which fits the nozzle snugly, nor do we in- 
crease the propelling pressure; we simply keep, with the 
syringe in position, the bulging urethra filled, aud pause 
for a while. The compressor soon tires out. We cause the 
patient to perform inspiration and prolonged expiration. 
Under the continued pressure of the liquid and the nega- 
tive abdominal pressure at the height of the expiration, the 
compressor soon relaxes, and the fluid enters the posterior 
urethra and the bladder. This is evidenced by the collaps- 
ing of the ballooned urethra. Now the piston is pushed 
slowly forward, and the fluid enters the posterior urethra 
and bladder without impediment. The patient is allowed 
to void the fluid in the natural way. 

After this procedure, which must be repeated until the 
fluid returns clear, the patient takes the knee-elbow posi- 
tion, and the right index finger, protected as before, is in- 
troduced in the rectum. Here again we have to change 
our mode of procedure. We will now get at the prostate 
directly, which will be felt as a flat, semicircular tumor, 
consisting of two lobes, with a central longitudinal fur- 
row, and occupying the anterior aspect of the rectum. 

The examining finger will at the same time make us 
cognizant of the density, texture, and size of the organ. 
A chronic diffuse prostatitis will cause, besides a mostly 
unilateral enlargement, a bulging into the rectum with an 
even or slightly nodular surface. A chronic parenchy- 
matous process, where groups of glands break down, form- 
ing pus-cavities, will reveal soft, doughy places painful to 
the touch. Cystic enlargement of portions of the prostate 
due to retention by occluded or clogged ducts will impart 
the same sensation to touch, but cause little or no pain 
owing to the non- purulent character of the contents. But 
as these objective symptoms are variable and cannot be 
depended upon solely, only the expressed contents of the 
gland will enable us to form an opinion. 

In order to do this we now gently press upon the gland 



232 CHRONIC URETHRITIS 

by lateral and vertical stroking motions directed downward 
and backward towards the operator, and there will soon 
escape a few drops of a white viscid and limpid fluid from 
the meatus. This we receive directly on three slides. One 
is used for an immediate microscopical examination, while 
the other two are reserved for examination with stains, 
to search for gonococci. In order to ascertain whether 
we have to deal with prostatic secretion, we add to the drop 
on the first slide a drop of a one per cent solution of phos- 
phate of ammonia, put on a cover- glass and allow it to dry. 
This will bring out Boettcher's crystals, the main attri- 
butes of every prostatic secretion. 

Next in frequency to appear are the stratified amyloid 
bodies showing concentrical rings. They are readily dis- 
cernible, but can be better recognized by the addition of a 
drop of Lugol's solution (iodin 1.0, iodid of potassium 2.0, 
ag. dext. 100.0). The secretion will further show hyaline 
and lecithin bodies, looking like minute fat -globules, as 
frequent, but not always present, elements of normal pro- 
static secretion. If, in addition to these, we find leucocytes, 
red blood -corpuscles, and numerous or grouped cylindrical 
epithelium in the specimen, the diagnosis of chronic pro- 
statitis is established. The second and third slides solve 
the question whether there are gonococci present or not. 
In order to decide this, Ave proceed to dry, fix, and stain 
one specimen with methylene blue and decolorize the other 
after Gram's method in the manner described elsewhere 
(p. 22) . In very doubtful cases, and when marriage is con- 
templated, cultures should be resorted to. 

Expression of the seminal vesicles is the next and final 
step to ascertain the condition of that organ in order to 
determine in what degree, if any, it participates in the 
process of chronic gonorrhea. 

The preliminary steps in cleansing the anterior and 
posterior urethra and in washing the bladder are the same 
as in the previous instances. The manipulating index 



PALPATION AND EXPRESSION OF GLANDS 233 

finger is now introduced beyond the prostate, but without 
exerting any pressure on it, and as high up as possible. 
As the seminal vesicles are situated laterally, their ducts 
converging towards the sinus prostaticus, the finger must 
necessarily be stretched to its greatest extent in order to 
reach the vesicles. If spermatocystitis gonorrhoea exists, 
as it is liable to in most cases of long-standing suppur- 
ation of the posterior urethra, the enlarged and engorged 
pouches will be readily found and "stripped" after the 
method of Fuller who recommends stripping of the seminal 
vesicles as a curative agent. The secretion so obtained by 
the massaging finger-tip, will show up at the meatus when 
present in sufficient quantity. It is received on slides and 
first subjected to microscopical examination without drying 
and staining. The presence of spermatozoa is, of course, 
the cardinal sign that the procedure was successful, and 
establishes the diagnosis. The admixture of leucocytes and 
probably of a few red blood -corpuscles will be evidence 
of an existing vesiculitis. In order to determine the pres- 
ence of gonococci, the specimen must be dried, fixed, and 
stained in the manner described elsewhere. In doubtful 
cases we will have to resort to cultures. But there are 
cases in which the massage of these glands will not cause 
their contents to appear at the meatus. As to the pros- 
tate gland this will be the exception, but the seminal vesi- 
cles very often do not yield secretion enough to traverse 
the distance to the meatus. In either of these instances 
the viscid, opalescent, residual urine, or injection fluid 
voided immediately after the manipulation, will contain the 
elements pertaining to each of the glands. By allowing 
the urine to settle or, better still, by centrifuging it, we can 
obtain material for microscopical examination. But it 
should be noted as regards the prostate that, from this speci- 
men, Boettchers crystals cannot be demonstrated, as the 
ammonia phosphate test does not materialize in the pres- 
ence of urine. The spermatozoa are easy of demonstration.] 



231 CHRONIC URETHRITIS 

OBSERVATION OF PATIENTS 

Treatment cannot be rationally begun and pursued un- 
less the diagnosis is established with precision, and the 
course of the disease be constantly watched; it will be 
indispensable to take the history of each patient, because 
the most faithful memory cannot retain all the details. 
We insist on this point, since faults of memory might have 
deplorable results. The observation should include espe- 
cially all the details observed by the endoscope at the 
time of the first examination, and all the changes which 
are subsequently noted. We should note each time the de- 
gree of dilatation reached, as well as the results obtained, 
and the symptoms complained of by the patient. The fol- 
lowing, for example, are the observations made upon sev- 
eral patients affected with various simple forms of urethritis 
which we have described. These observations are given 
wholly from the point of view of treatment by dilatations. 
Therefore we have put down neither the washings, the 
symptomatic treatment, nor the search for gonococci, etc. 
[This should never be omitted in record keeping.] 

Chronic Urethritis; Hard Infiltration of the First Degree, 
Glandular Form Without Complications 

M. B. 24 years. No antecedents of genito-urinary trouble. 
Infection six months ago. At present muco-purulent discharge in 
minimal quantity. Exacerbations after excesses of all kinds. Urine 
of the first glass filled with threads. 

May 1. — Urethroscope number 23. The bulbar region is normal, 
the middle third of the canal is red, swollen, having large folds; the 
anterior third is irregularly scattered with glandular orifices and 
swollen lucuna? which are red. The mucosa in this region is pale and 
smooth, forming thick, rigid folds. Dilatation to number 28. 

May 10. — Tube number 27. The redness of the middle third has 
disappeared. The infiltration is well limited to the anterior third 
where the zones of infiltration are clearly seen to be flat and of va- 
riable size, containing inflamed glands and lacunae. Dilatation to 
number 30. 



PALPATION AND EXPRESSION OF GLANDS 235 

May IS. — Tube number 27. Plaques of infiltration less pale, 
glandular orifices smaller, folds of the mucosa more supple and 
finer. Dilatation to number 32. 

June G. — Mucous membrane uniformly colored in the whole extent 
of the anterior canal: few glandular orifices visible; mucous mem- 
brane finely folded, excepting at about two centimeters from the 
meatus where there still exists an infiltrated zone. Dilatation to 
number 34. The patient sees no flow: the urine contains only 
mucus-shreds. 

June 23. — The infiltrated zone presents a red-surface, slightly 
desquamating, with some inflamed glandular orifices. Dilatation to 
number 35. 

July 3. — Desquamation is no longer visible, and the mucous mem- 
brane is smooth ; some glandular orifices still visible, have a normal 
appearance. Cured. 

August 9. — Cure still maintained. 

Chronic Urethritis; Hard Infiltration of the First Degree, 
Dry Form 

F. 29 years. Gonorrhea seven years ago. Rapid improvement. 
Since this time the patient has seen no discharge, and considering 
himself well, has believed that a complete cure was effected. For 
about three months he has noticed that in the morning the meatus is 
moist, and that in pressing the canal he could squeeze out a small 
quantity of pus. 

February 1. — Urethroscopic tube, 23. At the bulb the mucous 
membrane was reddish and of velvety aspect, uniformly dull; further 
forward the color is paler, the folds are irregular, and the surface is 
in a state of desquamation. In the middle of the penile region the 
membrane is pale rose color with large folds. Further forward, the 
membrane is nearly normal, but presents a few scattered orifices of 
glands which are not inflamed. Dilatation to number 27. 

February 14. — At the bulb the redness has disappeared and the 
longitudinal striations are seen again. Further forward, status quo. 
Dilatation to number 29. 

March 4.— Same condition. Dilatation to number 31. The pa- 
tient notices no discharge. 

March 19. — The membrane of the penile region becomes more 
moist and shining. A few swollen glandular openings. Dilatation 
to number 32. 

March 30. — Dilatation to number 33. 

April 10. — Dilatation to number 34. 



236 CHRONIC URETHRITIS 

i 

April 21. — Epithelial desquamation is no longer noted. The 
longitudinal striae have slightly reappeared. The folds are normal. 
The membrane is moist, smooth, shining. The few glandular orifices 
visible are without pathological features. 

May 1. — Same condition. Cured. 

Chronic Anterior Urethritis; Hard Infiltration of the Sec- 
ond Degree, Glandular Form. 

D. 37 years old. Gonorrhea three years ago. Persistent dis- 
charge disappearing at times for a few weeks, only to reappear with- 
out any appreciable cause. 

January 9. — Tube number 23. Region of the bulb uniformly 
bright red, slightly desquamating. The anterior two-thirds of the 
canal are pale and scattered with red plaques of slight brightness. 
The normal striae have disappeared, the folds are few and thick. The 
glandular orifices are red and prominent. The infiltration is espe- 
cially marked at the union of the anterior third of the urethra with 
the middle third. We here meet with large nodules, which are prom- 
inent and studded with hypertrophied glands. Dilatation to num- 
ber 25. 

January 27. — Tube number 29. The bulbar region seems normal. 
In the anterior region the plaques of infiltration are better made 
out, the aspect is pale red and lusterless. The glandular orifices 
appear in large number. Dilatation to number 27. 

February 10. — Dilatation to number 29. 

February 20. — The discharge has disappeared. The urine shows 
purulent flocculi. Dilatation to number 31. 

March 2. — Tube number 29. The normal zone, at first limited 
to the bulb, extends forward. In the anterior third glandular orifices 
are still to be seen, with widely open mouths, some being surrounded 
with a violaceous red zone. Dilatation to number 33. 

March 19. — Tube number 29. We still meet with some hyper- 
trophic glands with wide openings. In the middle third rosy cica- 
trices appear, surrounding the glandular orifices and extending upon 
the neighboring mucous membrane. In the anterior third the normal 
striation reappears. The urine contains a few scattered threads. 
Dilatation to number 34. 

March 30. — Dilatation to number 35. 

April 9. — The anterior third is entirely normal. In the middle 
third the glandular orifices are scarcely any longer to be seen. In the 
lower wall a linear cicatrix is noted, due to the dilatations and trav- 
ersing old glandular areas. Dilatation to number 36. 



PALPATION AND EXPRESSION OF GLANDS 237 

April 19. — The m*ine is quite limpid. Slight mucus-threads. 
Dilation to number 37. 

April 30. — Dilatation to number 38. 

June 2. — The mucous membrane has recovered its normal color 
throughout, it is brilliant and falls into folds like a healthy mem- 
brane. The striations are noticeable. In the middle third are still 
to be seen a few orifices of glands without any appearance of in- 
flammation . 

Chronic Urethritis; Infiltration of the Second Degree, 
Dry Form 

P. 40 years of age. Gonorrhea fifteen years ago. No compli- 
cations. The discharge continued for a long time, and for several 
years the patient saw a morning drop when any sort of excess had 
been committed the night before. For the past six months the dis- 
charge has reappeared. 

March 26. — Tube number 23. This passes the penile portion in 
giving a uniform sensation of resistance. The mucous membrane in 
the whole length of the canal is rosy gray and of dry and dull aspect, 
presenting in no part the usual striation. No folds, no glands in the 
anterior third, the canal remains open. The tube has caused a slight 
tear in the middle of the penile region, which has occasioned a slight 
hemorrhage. Dilatation to number 25. 

April 5. — Dilatation to number 26. 

April 16. — Dilatation to number 27. 

April 30.— Tube number 25. The bulbar region has taken on 
again a more rosy appearance ; the middle third folds, and a few 
glandular openings are seen. Dilatation to number 28. 

May 10. — Dilatation to number 29. 

May 20. — The discharge has disappeared. Purulent flakes in the 
urine. Dilatation to number 30. 

May 30. — Dilatation to number 31. 

June 12. — Tube number 27. The posterior third seems normal, 
the middle third folds quite well, and takes on a bright red color. 
Dilatation to number 32. 

June 25.— Dilatation, 33. 

July 1.— Tube number 29. In the middle third, the glandular 
orifices are less apparent. Dilatation, 34. 

July 12. — Dilatation, 35. Slight hemorrhage. 

August 1. — Tube number 29. In the anterior third large red 
folds begin to show themselves, the glandular orifices are quite 
visible. Dilatation, 35. 



238 CHRONIC URETHRITIS 

August 12. — The urine still contains some purulent flakes. Dila- 
tation, 36. 

August 22.— Dilatation, 36. 

September 1. — Dilatation, 37. 

September 15. — Dilatation, 37. 

September 27.— Dilatation, 37. 

October 15.— Dilatation, 38. 

October ^.—Dilatation, 38. 

November 30. — The membrane has taken on again a rose color 
in all parts and folds almost normally. The glandular orifices are 
normal. 

December 30.— Same state; no more flocculi in the urine. 



CHAPTER XV 

CHRONIC GONORRHEA AND MARRIAGE* 

[There is still a controversy in reference to the time 
as to when the gonococcus should be looked upon as 
definitely extinct from the uro -genital apparatus. The 
whole question, which was brought out with such vehe- 
mency at the Sixth Congress of the German Dermato- 
logical Society at Strasburg, in 1898, is still unsettled. In 
one point all parties agree, namely, that the gonococcus 
must be destroyed in order to effect a cure. While Beh- 
rend and his followers maintain that they can accomplish 
this by the use of astringents, as of old, Neisser and his 
disciples have shown that the silver- salts (Largin, Pro- 
targol, etc.) are capable of annihilating the gonococcus 
with a certainty not achieved by any other known agent. 
But the whole question becomes a mooted one when the 
infectiousness of chronic gonorrhea is considered. 

It goes without saying that, as long as there are gono- 
cocci present, no matter how few in number, the discharge 
is infectious; but the matter becomes complicated when 
they reappear after repeated painstaking examinations have 
failed to demonstrate their presence. The adnexa of the 
uro -genital apparatus furnish ample hiding places for their 
continued propagation. These are the subepithelial and 
connective tissues, the lacunae of Morgagni, Littre's glands, 
and other follicular structures, the prostate, the seminal 
vesicles, and the efferent ducts grouped about the collicu- 
lus seminalis or caput gallinaginis. In few cases of gonor- 
rhea is the infection limited only to the anterior portion of 

*By the editor. 

(239) 



240 CHRONIC URETHRITIS 

the urethra or to its superficial structures. Such cases do 
exist, but unfortunately the}' are few. The path by which 
the gonococcus reaches the deeper structures is a wide- 
open one to its ingression. In its strife with the leuco- 
cytes, by invading them, and in its being carried off and 
toward the surface by the same power which it was bent 
on destroying, the gonococcus will, under certain condi- 
tions, settle itself in the deeper structures. The gonococ- 
cus has been considered heretofore as chiefly an epithelial 
and intercellular parasite — one which thrives on the pro- 
toplasm of the leucocytes. Recent researches have shown, 
however, that it is not only capable of infesting the con- 
nective tissue, but that it may provoke suppuration there 
and be carried away bodily, so to say, by the blood- and 
lymph-channels to remoter regions, causing a veritable 
metastasis. 

In chronic gonorrhea, therefore, the habitat of the 
gonococcus will be found in the submucous and connective 
tissues and in the ducts of the different follicular struc- 
tures. If we now subject the scanty surface discharge of 
such cases, which hardly show any clinical symptoms, to a 
microscopical examination, we will mostly find mucus, 
muco-pus, epithelium in its different transition forms, bac- 
teria, and sometimes a few ill -defined gonococci; but 
mostly none at all. We thus pronounce the gonorrhea 
cured, and the patient as not infectious. The fallacy of 
such an opinion may manifest itself in a shockingly sur- 
prising manner by causing a gonorrheal infection in the 
female, or vice versa. Schiller, in examining three hundred 
women, maintains that when gonococci were present clini- 
cal symptoms were never wanting. Kollman has found 
gonococci in thirty per cent of his cases of chronic pros- 
tatitis, where no clinical symptoms were evident. Kapi- 
towsky, in examining one hundred prostitutes, found in 
eight per cent of the cases gonococci in their cervical dis- 
charges. These women had been declared — clinically — recov- 



CHRONIC GONORRHEA AND MARRIAGE 241 

ered, and discharged. Neisser has always claimed that 
gonococci may be present in the female genitalia, even 
when subjective symptoms and other microscopical signs 
are wanting. These and kindred questions emanate from 
the fact that in some continental countries the law provides 
a registration of prostitutes, a weekly medical examination, 
and gratuitous treatment in hospitals. They are dis- 
charged when a repeated microscopical examination fails 
to show the presence of gonococci. Although not be- 
longing within the scope of this treatise, we must touch 
the subject, as the possibilities of the protean aspect 
of the gonoccocus may, with some modifications, be ap- 
plied to the male also. Besides, the life-history of the 
gonococcus in the female is of more than paramount inter- 
est to ns. The registering of puelhe public*, so alien to 
the American idea of consideration even towards fallen 
women, only partly removes the opportunities of infection; 
while the greatest danger lies in continental countries, as 
well as in ours, in clandestine prostitution. Nothing short 
of educating the masses to the perception of the great so- 
cial danger which lies in an attack of gonorrhea, or legis- 
lation like that of the state of Michigan, will mitigate its 
ravages, and save hecatombs of wrecked lives in both 
sexes, but especially of women. 

The question naturally arises, is gonorrhea curable 
and, if so, when may we pronounce a gonorrhea cured ? 
Excellent observers, like Behrend and his followers, hold 
that gonorrhea, especially in the female, is incurable, and 
some gynecologists coincide in this pessimistic view. Xo 
doubt there is ample ground for such an opiuion. Those 
who have had occasion to view the specimens gained by 
operative interference on the female pelvic organs, will 
bear witness to the ravages wrought on the uterus and it 
adnexa by the ascending gonorrheal infection. In the 
male, strictures, chronic prostatitis, seminal vesiculitis with 
its attendant prostato- and spermatorrhea, sclerosing epi- 



242 CHRONIC URETHRITIS 

didymitis, bladder and ascending kidney affections, will 
bear out the unenviable record of the persistency of the 
gonococcus. And yet in the face of all these overwhelming 
proofs, we are free to assert that gonorrhea is a curable 
disease. We admit that the gonococcus, once having in- 
vaded the deeper structures, is hard to eradicate, and that 
the tissue-changes due to its action are well-nigh irre- 
parable; but are not these dire results due to the rough 
empiric methods of treatment handed down to us from time 
immemorial; when astringents were the Alpha and Omega 
of local treatment in acute gonorrhoic urethritis, and 
nauseating balsamics had wound up a cure which, in a few 
in stances only, could be looked upon as such \ 

In those times, when the causative factor of gonorrhea 
was conjectured but not yet discovered, the want of such 
an etiological knowledge had biased the greatest minds, 
and hence the treatment necessarily could not be other than 
empiric. But this has changed since Neisser's discovery of 
the gonococcus, and the researches made by Steinschneider, 
Schaffer, Schlangenhausen, Gohn, Wasserman, and others 
about the morphology and biology of that microbe. These 
researches culminate in the following facts: The gono- 
soccus is the only causative factor of gonorrhea. It trav- 
erses cylindrical epithelium with predilection, but under 
favorable circumstances attacks pavement epithelium also, 
especially by way of fissured interstices, and may settle 
m the deeper structures of the mucosa and adjacent con- 
nective tissue. It and its toxins exert an inflammatory 
action on the blood-vessels, causing them to become per- 
meable to the white blood -corpuscles and to the exudation 
@f pus -serum. The gonococcus and its toxins are pyo- 
genic, and both of them may cause metastasis in almost 
any organ of the body by way of the blood- and lymph- 
ghannels. 

But these untoward effects of the gonococcus may, in 
a measure, be avoided if Neisser's teaching and the treat- 



CHRONIC GONORRHEA AND MARRIAGE 243 

ment pointed out by him is better understood and practiced. 
It is his etiological treatment of acute gonorrhea with the 
soluble silver -salts which, up to the present, cannot be 
superseded by anything else. Their penetrating power to 
destroy the microbe, even in the deeper strata of the mu- 
cous membrane, is unequaled. When these facts will be- 
come better known to the profession, auto -reinfection by 
gonococci, permitted to become latent in the deeper struct- 
ures, will become a rarer event, and the prognosis of gon- 
orrheal infection in both sexes will be a more hopeful one. 

To turn to the question of marriage of a patient who 
has had gonorrhea, the physician will have a highly re- 
sponsible question before him to decide. We here emphati- 
cally take the stand against Kromayer's contention that 
the physician shall decline the responsibility of deciding. 
Patients yet infectious will then marry in larger numbers 
than now, without asking their physician whether they are 
justified to do so. Let us utilize the only exact method 
given us by Neisser, which is to search for gonococci. 

We start with a given case of chronic gonorrhea. 
The patient wants to know whether he is yet capable 
of infecting, and makes his matrimonial venture de- 
pendent upon our finding. We have repeatedly exam- 
ined the threads in his urine, and have found no gono- 
cocci under the microscope. On the strength of this 
examination shall Ave pronounce this man cured? Cer- 
tainly not. We will bear in mind that there might be 
gonococci in the subepithelial and connective structures, in 
the glands of Littre, in the lacuna? of Morgagni, in the 
prostate, and in the seminal vesicles. What means do we 
possess to entice these parasites to the surface ? We will 
apply to the urethra a provocative injection of either a two 
per cent solution of nitrate of silver or an irrigation of a 
warm solution of bichloiide of mercury, 1 in 10,000 — 
preferably the first one. A reactive irritation of the 
mucous membrane will follow, and a discharge, more or 



244 CHRONIC URETHRITIS 

less copious and of short duration, will establish itself. 
We will find leucocytes, epithelia in various transition 
forms, mucus, and gonococci if such were present in the 
deeper structures. But right here the gravity of the ques- 
tion sets in. The presence of gonococci is proof positive, 
and needs no further confirmation. But if repeated and 
thorough examinations have failed to show the presence of 
gonococci, are we just as positively enabled to draw our 
conclusions from this negative result! Certainly not. 
There are several possibilities: (1) There are really no 
more gonococci present. (2) There might be gonococci 
present, but we have failed to demonstrate them either 
because of faulty technique or because the provocative dis- 
charge had not dislodged them. (3) The discharge con- 
tains pus -corpuscles in abundance, but no gonococci. 

To determine the first two points and make sure that 
there are no more gonococci present, or if supposedly 
present, we have somehow failed to demonstrate them by 
the microscope alone, we must have recourse to another 
process of examination, namely, to cultures. The best 
culture -medium for the gonococcus is human chest serum- 
agar, mentioned elsewhere in this volume (p. 25). To 
inoculate such a tube or plate, and breed the germs in an 
incubator, will be an easy task for those possessing the 
knowledge of bacteriology and an outfit. Those not versed 
in such researches will do well to send the specimen to a 
laboratoiy for examination. 

The practitioner in this country is getting accustomed 
to send the culture -tube inoculated by him with the exuda- 
tion of his patient's throat to the bacteriological depart- 
ment of his board of health, in order to obtain a bacteri- 
ologic diagnosis of diphtheria. We sincerely hope that 
hypercritical moralists will not obstruct legislation if, by a 
concerted action of medical societies, the local boards of 
health would be obliged or permitted to examine gratui- 
tously, or for a small fee, the suspicious secretions or 



CHRONIC GONORRHEA AND MARRIAGE 245 

threads. This could be done by collecting the pus or the 
threads in a small sterilized test-tube, and sending it in 
for examination. 

Heiman has shown that from the contents of such tubes, 
when sown on plates, the gonococcus could be obtained and 
isolated when brought to the laboratory, hours later. The 
mode of obtaining the threads in the usual way, by fishing 
them out of the urine, is a faulty one, and does not per- 
mit of a conclusive answer. In case of a negative result, 
even if Gram's decolorization had been used, we will 
always entertain some misgivings whether one or the other 
of the unexamined threads might not perhaps have con- 
tained gonococci. Therefore we deem it indispensable, in 
order to exclude any fault in the technique, to avail our- 
selves of the centrifuge. 

It seems that Heiman was the first to employ the cen- 
trifuge in connection with culture -media for the collection 
of gonorrheal threads. The threads thrown down by the 
centrifuge are afterwards inoculated on the culture -me- 
dium. Thus we are sure that all available threads have 
been planted, and if gonococci are present, they will cer- 
tainly show up in colonies. These are now subjected to 
a microscopical examination. It is essentially necessary 
that the decolorization by Gram's method be used, as this 
alone furnishes a reliable criterion in determining whether 
the culture is or is not that of a gonococcus. The exam- 
ination of cover -glass preparations, first with the methy- 
lene -blue staining, and then after Gram's method, gives 
for all practical purposes very satisfactory results. But 
in deciding the advisability of marriage we must avail 
ourselves, not only of a thorough clinical and microscopi- 
cal, but also and foremost of a bacteriological examina- 
tion, with the use of Gram's method. 

When using the urine, that is, the filaments or threads 
suspended therein, for cover -glass examination only, we 
will direct the urine to be voided in two portions. It is 






246 CHRONIC URETHRITIS 

best to centrifuge it, even for this purpose. In a gross 
way, the first portion will contain the threads of the an- 
terior urethra, the second the secretion of the posterior 
urethra, and probably of the prostate if pressed upon 
while urinating. It has been shown elsewhere how to pro- 
ceed when we desire to determine the locality whence the 
threads or the expressed material are coming. For sim- 
ple cover- glass examination we will place the thread on a 
slide, spread it out with a sterilized platina loop, dry it r 
draw it through the flame, stain it with methylene -blue, 
and examine it under oil -immersion. As a control -test 
we will employ Gram's method of decolorization. 

If the result of this examination is questionable, we 
will then at once resort to a bacteriologic investigation. 
For safety's sake we advise to plant cultures even then T 
when microscopical examinations have repeatedly yielded a 
concurring negative result. Cultures will then determine 
with an absolute certainty the presence or absence of the 
gonococcus. 

As regards the third possibility, when the secretion 
contains mostly pus -cells as its morphological constituent; 
we have then to deal with a blennorrhagic process either 
of a mixed type or a secondary infection. In such a case 
the gonococci have vanished for good. Either the soil 
has been made inimical to their growth by other cocci not 
yet determined, or the gonococcus might have under- 
gone disintegration through hyperplastic connective -tissue 
changes (strictures) caused by its protracted presence 
there. We regard such a case in a sense infectious, and 
pronounce it as such to the candidate for marriage until 
his bacillary or catarrhal urethritis is cured. 

As the matter stands at present, there are two views cur- 
rent as regards chronic gonorrhea and permission to marry. 
Those who advocate the decision of the question on a purely 
clinical basis, and those who hold the opinion that only 
microscopical and bacteriological examination should be 



CHRONIC GONORRHEA AND MARRIAGE* 247 

decisive. It is the old controversy between Behrend, who 
adheres to the old astringent treatment of gonorrhea, and 
Neisser, the founder of the microbic origin and etiological 
treatment of gonorrhea with the silver -salts. Behrend and 
his followers, Broeze, Schiller, Kromayer, and others, 
maintain that "the demonstration of the gonococcns has a 
positive value only in those cases w r here other clinical 
methods make its use superfluous, while in other cases 
their demonstration is so unreliable as to be valueless. * 
In the face of the indubitably exhaustive microscopical 
and bacteriological researches of Neisser, Ernest Frank, 
Janet, Finger, and a host of other investigators, the con- 
tention of the former investigators is an untenable one. 
The antiseptic treatment of gonorrhea in connection with 
examination for gonococci is without doubt the only- 
rational method at present. It rests on exact scientific 
facts, and cannot be replaced by a solely clinical aspect 
of the matter. 

Kromayer maintains in a recent publication that the 
physician has no right to give permission to marry even 
after repeated examinations have shown that no gonococci 
are present. While we are perfectly aware that such may 
be lurking somewmere in spite of all our endeavors, yet 
there must be a line drawn, or else about ninety per cent of 
the male population would be condemned to celibacy. 
Nothing short of mathematical accuracy to demonstrate the 
non- infectiousness of the individual would satisfy the 
opponents. But how few, if any, are the instances in our 
science and therapy where absolute assurance is possible or 
required? The surgeon removes the cancerous neoplasm 
with the relative assurance of restitution. Can he be 
blamed when, after all, general carcinomatosis develops? 
It is agreed that syphilitics may marry after they have 
undergone systematic treatment, when four or five years 
have elapsed since the onset of the infection, and at least 
one year after the last specific symptoms have existed. We 



248 CHRONIC URETHRITIS 

know that they marry with reasonable security, and we 
do know that healthy offspring* is begotten. Why then 
shall gonorrhea alone be on the proscription list? Surely 
the syphilitic taint is not less destructive than the gonor- 
rhoic infection. Of course it would be an ideal standpoint 
were we enabled to presage with absolute certainty the 
time when neither of them is again capable of infecting. 

But only the relative is our lot, the absolute is denied 
to us! To resume on what has been said on this topic, we 
take the stand that we will give jjermission to marry to 
those having had gonorrhea when, after repeated and care- 
ful microscopical examination of slide specimens and ex- 
haustive bacteriologic and microscopic investigation of the 
threads and the secretions of the prostate and seminal 
vesicles, done under the strictest rules and with the aid 
of Gram's method, the presence of gonococci cannot be 
demonstrated.] 



CHAPTER XVI 
CONCLUSIONS 

Chronic gonorrhea of the urethra in man is an affec- 
tion of invading character; its lesions, which may in- 
volve all the constituent elements of the canal, are the 
result of the evolution of a neoplastic infiltration set up 
by the presence of the gonococcus. 

The gonococcus may remain in the canal during the 
course of chronic urethritis, that is to say, during an 
indefinite time. Its virulence may then become attenu- 
ated, and only show itself by the invading character of the 
lesions and the obstinacy of the disease. It may also 
begin again after a period, and thus give to the affection 
the acute or contagious character which it had seemed to 
have lost. It is impossible to determine at what moment, 
the gonococcus having disappeared, the disease ceases to be 
transmissible. 

The gravity of chronic urethritis results, first of all, 
from the complications of all kinds which it can produce 
in man; it depends, besides, upon the danger of contagion 
and the redoubtable series of genital accidents that it pro- 
duces in woman. 

It is, therefore, an absolute necessity to cure chronic 
urethritis in man. 

To succeed in attaining this end we must, first of all, 
establish a precise diagnosis based upon a complete method- 
ical examination of the patient, dealing with the patholo- 
gical secretions which are presented under the form of a 
discharge, or of flocculi floating in the urine. 

We must know the nature of these secretions, as 

(249) 



250 CHRONIC URETHRITIS 

to whether they contain gonococci, and endeavor to de- 
termine their origin. We will investigate, especially, 
whether they come from the anterior portion of the canal, 
or from the posterior region, and whether the bladder 
and the prostate are also diseased. 

We must then proceed to the examination of the ad- 
nexa of the urethra, and chiefly to that of the prostate. 

Finally, we will examine the canal itself. We will 
make use of the various well-known explorers — bougies, 
bougie a boule, urethrometers, etc., and have recourse also 
to the urethroscope. 

The employment of this instrument in the diagnosis 
and treatment of chronic affections of the urethra has a 
value analogous to that of the ophthalmoscope, laryngo- 
scope, etc. 

Among the urethroscopes employed today there is only 
one which gives satisfactory results: that is the urethro- 
scope of Oberlander. 

This permits us to illuminate the urethral mucous mem- 
brane so as to perceive the minutest details. The advan- 
tages of this instrument are considerable; therefore it 
ought to be preferred to all others. [The newer urethro- 
scopes, with mignon lamps and without water -cooling de- 
vice, are of course preferable. They are built after Ober- 
lander' s model.] 

The urethroscope should not serve for diagnosis only, 
but we must rely upon it during the whole course of treat- 
ment, as it enables us to follow the course of the cure and 
to properly apply the principles of therapy. We know of 
only one means of acting directly upon the fibrous infiltra- 
tion which constitutes the essential lesion of chronic ure- 
thral gonorrhea: this is dilatation. 

Dilatation may be carried out by means of bougies, but 
in this way we do not reach a complete result, because the 
caliber of the canal is not uniform through its whole extent. 
The dilators, however, conform perfectly to this require- 



CONCLUSIONS 251 

ment; thanks to their use we surely do succeed in setting: 
up resorption of all the infiltration tissue capable of dis- 
appearing-. The parts which cannot be made to undergo 
absorption are transformed into indifferent cicatricial 
tissue, incapable of giving; rise to recurrence or to trans- 
mission of the disease. 

The use of dilators cannot be left to chance, under 
penalty not alone of complete failure, but also of the risk 
of producing irritation and traumatic lesions. The rules 
which should govern the use of these instruments vary ac- 
cording to the form of urethritis we have to deal with, 
and their ensemble constitutes a special method of treat- 
ment. If we wish to attain a complete cure, it is indis- 
pensable to adhere scrupulously to them. Under these 
conditions we may be sure of success. 

To declare a case of urethral gonorrhea cured we must 
show: 

1. That there is no longer any trace of purulent secre- 
tion (discharge, urinary filaments). 

2. That the canal no longer shows any kind of inflam- 
matory lesion when examined through the urethroscope, 
that the foci of infiltration, whose resorption we have not 
been able to obtain, should have passed into the con- 
dition of indifferent cicatrices, as the end -stage of their 
evolution. 



PLATE I 

Fig. 1. Normal Urethra with Vascular Mucous Membrane. Mu- 
cous membrane with smooth and brilliant surface. Radiating folds 
fine and multiple (longitudinal folds). Longitudinal striation. Punc- 
tiform central figure (middle portion of penile urethra). 

Fig. 2. Normal Urethra with Anemic Mucous Membrane. Mucous 
membrane pale and yellowish, with smooth and brilliant surface. 
Folds fine and less numerous. The striation of the vascular mucous 
membrane scarcely visible, above light vascular arborization. Cen- 
tral figure oval. (View taken from the entrance of the canal be- 
hind the glans penis). 

Fig. 3. Soft InMtration {Acute Urethritis; beginning of the chronic 
form). Mucous membrane uniformily inflamed, hyperemic, brilliant. 
Epithelium swollen. A few large folds close to the central figure. 



(252) 



PLATE II 

GLANDULAR URETHRITIS 

Fig. 4. Glandular Urethritis. Hard Infiltration of the First Degree 
{before treatment). Infiltrated mucous membrane. Epithelium in 
state of desquamation. Central figure closed by large irregular folds. 
Striation obliterated. Above and to the left, two plaques of pale in- 
filtration with red punctiform orifices of inflamed glands of Littre. 
To the right, an inflamed Morgagni crypt, open and prominent. 
Lower, two hypertrophic orifices of Littre glands. 

Fig. 5. Same form and degree as Fig. 4 {after the first dilata- 
tions). Mucous membrane less infiltrated. Epithelium less desquam- 
ating. Folds smaller and more numerous. The orifices of Littre' s 
glands, which were simply inflamed in the infiltration plaques, have 
disappeared. The swelling of the orifices of the glands and crypts 
have diminished, other orifices have shown up after the swelling of 
the mucous membrane has gone down. 

Fig. 6. Same form and degree as Figs. 4 and 5 {nearly cured). 
Mucous membrane has a nearly normal color and reflection. Folds 
irregular. Striations have reappeared. Epithelium regular. Orifices 
of the glands and crypts free from swelling and of nearly normal 
color and aspect. 



(254) 



Fw 4 




Flo 6 





PLATE III 

DRY URETHRITIS 

Fig. 7. Dry Urethritis. Infiltration of Second Degree {before 
treatment). Mucous membrane has the aspect of dead skin, without 
folds, without striation. Epithelium dry, without the slightest bril- 
liancy and in state of desquamation. Central figure widely open, 
base obscure, indistinct. Neither glands nor lacuna?. (Below we 
see the shadow of the light -carrier, the endoscopic tube is slightly 
inclined downward to disclose the upper wall of the urethra.) 

Fig. 8. Same form and degree as Fig. 7. Large submucous 
nodosities project into the endoscopic field. They are covered with a 
thickened epithelium in state of desquamation. 

Fig. 9. Dry Urethritis — Form with Vesicles — Hard Infiltration of 
First Degree (before treatment). Mucous membrane of dull and dirty 
aspect. Folds effaced. Striation visible in places. Epithelium in 
desquamation; not a single orifice of a gland nor of a lacunae. Numer- 
ous vesicles of various size and prominence according as they are 
situated more or less deeply in the mucous membrane. 

Fig. 10. Dry Urethritis. Infiltration of the Second Degree (after 
the first dilatations). Mucous membrane of a uniformly yellowish and 
dull aspect (cadaveric aspect). Epithelium dry, without glitter and in 
state of desquamation; neither glands nor lacunae. Below a red 
rhagade or fissure, the remnant of the last dilatation. Central figure 
open. 

Fig. 11. Mixed Urethritis. Hard Infiltration of the Second Degree 
(in course of treatment) . Mucous membrane of less cadaveric aspect. 
Central figure gaping; a few folds. Upon either side of the figure a 
prominent large vesicle of grayish appearance ; below, a crypt or 
gland with inflamed and partly opened orifice; same upon the side. 



(256) 



PLATE IV 

POSTERIOR URETHRITIS (MEMBRANOUS AND PROSTATIC 
PORTION) 

Fig. 12. Membranous Urethra in a Normal State. Mucous mem- 
brane fine and brilliant, uniformly well colored. Radiating folds, 
regular, delicate, and very numerous. 

Fig. 13. Urethritis of the Membranous Portion. Hard Infiltration 
of the First Degree (before treatment). Mucous membrane rosy with 
gray plaques, slightly yellowish, of dull aspect, dry. Epithelium 
thickened and in state of desquamation. The radiating folds, fine and 
characteristic of the region, are replaced by larger and less numerous 
folds. 

Fig. 14. Prostatic Urethra in Normal State. Below, the regu- 
larly rounded, yellowish rosy prominence of the verumontanum, with 
mucous membrane smooth and shining. All about, separated from 
the verumontanum by an ill -defined furrow, the mucous membrane of 
the upper wall of the urethra is of a darker red and of a slightly dull 
aspect. . Quite at the lower part, the circumference of the figure is 
encroached upon by the shadow of the light-carrier. 

Fig. 15. Urethritis of the Prostatic Portion. Hard Infiltration; 
Transition Form of Soft Infiltration {before treatment). Mucous mem- 
brane dull red, without life, yellower upon the verumontanum, which 
is swollen and slightly deformed by infiltration; the orifice of the 
prostatic utricle is gaping and slightly compressed on the side. Quite 
at the lower part is the shadow of the light-carrier. 



(258) 



INDEX 



Abscesses, periuretheral, 220. 

Acetate of lead, 173. 

^Erourethroscope of Antal, 68. 

Ammoniacal decomposition of urine, 
159. 

Amyloid bodies in prostate, 232. 

Anatomo-pathologic study (general 1 , 7. 

Anatomy of urethra, 9. 

Antiseptic astringents in chronic gon- 
orrhea, 185. 

Antiseptics, 177. 

Antrophores, 167, 195. 

Argentamine, 180. 

Argonin, 180. 

Argyrosis, 104, 177. 

Asepsis, urethral, Notes on 187, 188. 

Aseptic cathete-ism, 171. 

Aseptic discharge, astringents in, 156, 
175. 

Astringents, 172; action of, 144, 175; 
indications, 17:J. 

Balsamics, 156.' 

Bernultz on latent gonorrhea, 2. 

Bismuth, injection of, 175. 

Bloch on natural elimination of gon- 

ococci, 183. 
Boettcher's crystals, 232. 
Bougies, 195; a boule, 64, 65; in chronic 

gonorrhea, 185. 
Bumm's culture medium, 25. 

Caput gallinaginus, 16. 
Catheterism, unclean, 188. 
Catheters without "dead space," 192. 
Caustics, 175. 

Chalot on rupture of bladder, 169. 
Chancres, intraurethral, 156. 
Chettwood's urethroscope, 71. 
Chronic gonori-hea and marriage, 239. 
Ciaetrices after stricture, 139; of ure- 
thra 116, 150. 
Cocaine anesthesia, 80. 
Collicus seminalis, 16. 



Compressor urethra?, causing closure 
of bladder, 55; relaxation of, 170. 

Conclusions — Epilogue, 249. 

Copaiba, 157. 

Copper sulphate, 173. 

Corpus spongiosum, urethra?, 12. 

Corrosive sublimate, 176, 177, 178. 

Cowper's (or Mery's) glands, 13, 14. 

Cowper's glands, palpation and expres- 
sion of, 227, 229. 

Cubebs, 157. 

Cysts, atrophied by dilatation, 93 ; of 
clogged Littre's glands and lacunar, 
11C, 126, 133. 

Diaphanoscope, of Casper, 68; of 
Schiitze, 68. 

Didays's method in m-ethro-cystitis, 
171. 

Dilatation, discharge after, 211,219; 
forcible, 219; general rules, 207; hem- 
orrhage in, 210, 219; in anterior ure- 
thritis, 213, 215; mode of action, 213; 
of posterior urethra 224, 225; treat- 
ment after, 217. 

Dilators, care of, 200; contra-indica- 
tions, 209; four-branched (Koll- 
man's), 200; irrigating (Kollman's), 
202; method of using, 202, 204, 205, 
208; preliminary precautions, 210; 
Oberlander's, 197, 198, 199; Otis', 
197, 198; rubber covers for, 202; 
steam sterilizer for, 205, 206. 

Disinfection of instruments, 191. 

Disturbances of sensation, 59. 

Drobny on location of gonococci, 183. 

Elastic instruments, sterilization of, 

190, 191. 
Electrolysis in chronic urethritis, 222. 
Elimination of gonococci by Nature's 

process, 183. 
Ejacailatory ducts, 16. 



(259) 



260 



INDEX 



Endoscopy (urethroscopy), 68; central 
figure of normal mucus membrane, 
87,104; central figure in hard infiltra- 
tions, 121; central figure .in soft in- 
filtrations, 121 ; central figure in 
strictures, 136; of the pathological 
urethra, 91; of posterior urethra, 140. 

Epithelium in pathological conditions, 
100, 103. 

Epithelium, invasion of by gonococci, 
29. 

Erectile layer of urethra, 12. 

Eschars produced by nitrate of silver, 
resorcin, zinc salts, 103, 104. 

Encaine anesthesia, 80. 

Examination, of patient, 63, 64. 

Expression of semi.-.al glands, knee- 
elbow position, 228; recumbent posi- 
tion, 227. 

Expression, technique of, 227. 

External sphincter, on the, 37, 55. 

Filaments, bacteriological examination 
of, 244; Fiirbringer on, 50; localiza- 
tion of, 52, 245; microscopical exam- 
ination of, 245; mode of obtaining, 
245. 

Finger on acute gonorrhea, 181, 182; 
on remedies for injections, 173; on 
pathological anatomy of acute gon- 
orrhea, 35. 

Five-glass test (Kollman), 55. 

Flaxseed tea in painful tenesmus, 160. 

Flushing (irrigation) of anterior ure- 
thra, 57, 167, 168, 169; of posterior 
urethra, 170, 230; with hand syringe, 
171; with nitrate of silver, 170, 176; 
without catheter, 169; with catheter, 
167. 

Folds, urethral, forming central figure, 
104; longitudinal, of normal urethra, 
13, 86, 104; longitudinal, partial re- 
appearance when cured, 105; trans- 
versal, 13. 

Foliae Uvae Ursi, 160. 

Formalin vapor, 192. 

Functional disturbances, 59. 

General treatment, 154. 

Glands, urethral, in pathological condi- 
tions, 106. 

Gonococci, in cervical discharge, 240; 
clinical study of, 28, 29; in connective 
tissue, 30, 34, 240, 242; cultures of, 25, 



26, 244; disintegration of, 246; dor- 
mant in Littre's glands, 3; dormant 
in Morgagni lacunae, 3; dormant in 
Cowper's glands, 3; dormant in the 
prostrate, 3; dormant in the seminal 
vesicles, 3; extension and generaliza- 
tion of. 30, 240; in prostrate, 240: 
inconstant in gonorrhea, 33, 240; in- 
oculation of, 27; in animals, 28; la- 
tent, 4, 31; metastasis of, and by its 
toxines, 27, 240; microscopical exam- 
ination of with and without cover- 
glasses, 20, 21, morphological features 
of, 23; persistency and increase of, 
31, 242; presence of, without clinical 
symptoms, 241; reappearance of. 220; 
receptivity in congestive pelvic condi- 
tions, 32; search for in marriage can- 
didates, 243, 244; staining process, 
details of, 17, 18,20,22; section-stain- 
ing, 19; toxines of, 26, 27, 32. 

Gonococcus of Neisser, 17, 182. 

Gonorrhea, acute, 35; aetiologic, treat- 
ment of, 179, 184, 242. 

Gonorrhea, chronic, antiseptics and as- 
tringents in, 185; curability of, 241; 
infectiousness, 239; Protargal in, 181; 
structural changes in, 185; treatment 
of, 179, 185; urethroscope in, 185. 

Gonorrhea, sounds in, 64, 185, 195; 
spontaneous recovery from, 184; ster- 
ility due to, 4. 

Gonorrheal peritonitis, 31; rheuma- 
tism, 27. 

Gram's method, 16, 23. 

Granulations, 98, 101. 

Grooved sounds (Casper's), 197. 

Guerin's valve, 13. 

Guyon's instillations, 162. 

Haematogenic infection, 193. 

Halstead's irrigations, 178. 

Hand syringe, large, 57; Janet-Frank's, 
57, 171; irrigations with, 58, 169; olive- 
shaped tip for, 57. 

Hard infiltration, 99, 112, 122, 124, 127, 
134; cicatrical tissue in, 98; epithe- 
lium in, 124, 128, 130, 136, 138; glands 
open or obstructed in, 92: lacunae 
in, 113, 114. 115, 129, 131, 133; Littre's 
glands in, 112, 113, 121, 124, 125, 129, 
131, 133; first degree (canal normal 
caliber), 94. 123; second degree (canal 
diminishing caliber), 94, 123; third 



INDEX 



261 



degree (stricture) 94, 134; recurrences 
in. 123. 

Herman, collection of threads by cen- 
trifuge, 245. 

Hemorrhage of urethra, 152, 210, 219. 

Ichthyol injections, 178. 

Incandescent mignon lamp (Koch's), 
70, 83. 

Injections, remedies for, 173. 

Instillations. 162; anterior urethra, 163: 
posterior urethra, 164; in chronic 
gonorrhea, 185; Guyon's, 162; nitrate 
of silver, 166, 175. 

Instruments, metallic, sterilization of, 
190, 191. 

Internal medication in chronic gonor- 
rhea, 156. 

Introduction, 1. 

Irrigating dilator (Kollmann's), 202, 
203. 

Irrigation of urethra (see under Flush- 
ing.) 

Irritability, sexual, 60, 61. 

Jadassohn's three-glass test, 53. 

Janet on gonorrhea, 155. 

Janet's irrigation, 167, 169; hemorrhages 

after, 169; tenesmus after, 169. 
Jointed obturator for posterior urethra, 

74, 141. 

Lacunas Morgagni, 13, 113, 114, 115; 
cysts of, 115; dormant gonococci in, 
3, 239, 243; in hard infiltrations, 113, 
115, 129, 131, 133, 137. 

Lamp-carrier, inclined form of Weiss', 
85. 

Lanolin for salves, 174. 

Largin in acute gonorrhea, 179, 180. 

Latency of gonococcus in bulbous reg- 
ion, 180; in the prostate, 180. 

Lavages, 167. (Also see Flushing.) 

Lesions met with in the tissues of 
canal, 96; in the epithelium, 100; in 
the folds, 104; in the glands, 106; in 
the mucous membrane, 96. 

Leucocytes in acute gonorrhea, 182, 183. 

Littre's glands, 14; cysts of, 110; dor- 
mant gonococci in, 3, 239, 243; ex- 
ceptional deep situation of, 106, 109; 
gaping ducts of, 108; in diseased con- 
ditions, 107, 112, 121, 124, 126, 131, 133; 



in posterior urethra, scarce or absent, 

111, 148. 
Local treatment, 161. 
Localization in chronic urethritis, 52, 

179. 
Loewenhardt's incandescent lamp. 'JO. 
Lohnstein's prussian-blue test, 57. 
Lubricants, 191, 207. 

Marriage, permission for, 243. 

Meatotomy, 196. 

Mechanical treatment, 195. 

Membranous sphincter 55. 

Mery's (or Cowper's) glands, 13. 

Metallic instruments, sterilization of, 
190, 191, 192. 

Metastasis by the gonoccoccus or its 
toxines 27, 240. 

Metchnikoff on phagocytosis 183. 

Methylene blue, 20, 157. 

Microbes of urethra, (non-pathogenic), 
28, 188. 

Mignon incandescent lamp (Koch's), 
70, 83. 

Mixed infection, 32, 246; antiseptics 
and astringents in, 156. 

Mucous catarrh, 107. 

Mucous membrane in soft infiltra- 
tions, 96; longitudinal striae of nor- 
mal, 88; color of normal, 85; pallor of 
in hard infiltrations, 97, 98, 99; nor- 
mal vascular ramifications of, 88. 

Mucous Urethritis, 107, 119. 



Neisser, gonococcus of, 17. 

Neisser, on silver-salts, 180. 

Nervines, 159. 

Neurasthenia sexualis, 60. 

Nitrate of silver, instillations of, 165, 

175; washings of, 156, 176, 185. 
Nitze on meatotomy, 196. 
Nitze-Oberlander's urethroscope, 69. 
Noegerrath on latent gonorrhea, 2. 

Oberlander's dilators, 197, 198, 199. 
Oberlander's dilating tube, 74. 
Oberlander's jointed obturator for the 

posterior urethra, 74, 83, 141. 
Oberlander's urethroscope, 68, 69, 73. 75. 
Observation of patients, 234. 
Ointment sounds, 197. 
Otis on meatotomy, 196. 
Otis on wide strictures, 94. 



262 



INDEX 



Otis' urethrometer, 66. 
Otis' urethroscope, 68, 79. 
Otis' dilator, 197, 198, 

Pachydermia, 102, 136. 

Palpation and expression of the seminal 
glands, 227. 

Panelestroscope of Leiter, 68. 

Papillamatous urethritis, 151. 

Papillamata, 146. 

Paraurethral ducts, 156. 

Peritonitis caused by the gonococcus, 31. 

Periurethral abscess, 220. 

Periurethral ducts, 156. 

Periurethral glands, 156. 

Permanganate of potash, 178. 

Phagocytosis, 35, 38, 183. 

Plates I, II, III, IV, 252-258. 

Polynuclear pus-cells, 21. 

Polypus of iirethra, 151. 

Porte-caustique, 177. 

Posner on disinfection of instruments, 
191. 

Posterior urethra in chronic ureth ritis, 
43, 144; in normal state, 143. 

Preface, iii. 

Presence of gonococci without clinical 
symptoms, 240. 

Prostate, amyloid bodies in, 232; dor- 
mant gonococci in, 3, 4, 230; expres- 
sion of, 230; follicles, 14, 16; prostatic 
utricule, 16. 

Prostatitis, in chronic gonorrhea, 227, 
231. 

Prostatorrhea, 62. 

Prostitution, dangers of clandestine, 
241. 

Prostitutes, registration of, 241. 

Protargol, 179, 180. 

Provocative injection, 243. 

Quantity of secretion. 49. 

Reappearance of gonococci. 220. 
Regimen, 154. 

Registration of prostitutes, 241. 
Relaxation of compressor at height of 

expiration, 170. 
Resorcin injections, 178. 
Ricord's mixture, 175. 
Rubber covers for dilators, 202, 203. 

Salicylates, 158. 
Salix Nigra, 159. 



Salol, 158. 

Santal oil, 157. 

Shaffer on gonococcus toxines, 27, 242. 

Sholtz on gonococcus toxines, 27. 

Secondary infection, 34, 155, 246. 

Secretions in chronic urethritis, 49; 
microscopical examination of, 50. 

Seminal vesicles, dormant gonococci 
in, 3 ; expression of, 232. 

Sexual neurasthenia, 60, 61. 

Silver-salts, soluble, 180, 181, 243. 

Soft infiltrations in epithelium, 119; in 
folds, 120; in Littre's glands, 112, 
121; in Lacunas, 121; in mucous mem- 
brane, 96; of posterior urethra, 145. 

Sounds, 64, 185, 195; Casper's, 197. 

Spermatorrhea, 62. 

Sphincter externus of ui*ethra, 12, 58; 
internus, vesical or prostatic, 12. 

Sterility due to gonorrhea, 4. 

Sterilization, elastic instruments, 190; 
metallic instruments, 191. 

Sterilizer (Kuttner's), 189, 190. 

Stricture, 185; in dry form of hard in- 
filtration, 99; in glandular form of 
hard infiltration, 99; of posterior 
urethra, 150; prolonged treatment 
by dilatation, 140; recurrence of, 140; 
spontaneous cure of, 137. 

Suppositories, urethral, 168. 

Suppuration, 49, 240. 

Syringes, 57, 193. 

Tears produced by dilatation, 139. 

Technique of urethroscopy, 79. 

Tenesmus by morphine, 160. 

Terminal contractions of sphincters, 
227. 

Thompson's two-glass test, 53. 

Threads, bacteriological examination 
of, 244; localization of, 49, 52, 246; mi- 
croscopical examination of, 245. 

Toumasoli's salve syringe, 174. 

Topical remedies, 172. 

Toxines of gonococcus, 26, 32, 184. 

Treatment, general, 154. 

Treatment of chronic gonorrhea, 179. 

Trigone of Lieutand, 16. 

Two-glass test, Goldenberg, 56; Thomp- 
son's, 53. 

Ultzman's drop-catheter, 164. 
Urethra, anatomy of, 9; bacterium coli 
in, 155; connective-tissue layer of , 11; 



INDEX 



263 



corpus spongiosum of, 12: dimen- 
sions of, 10; epithelial layer of, 11; 
erectile tissue of, 12; exploration of, 
188; external spincter of, 12; glans of, 
12; longitudinal and transverse folds 
of, 13; muscular coat of, 12; non-path- 
ogenic flora of, 28, 188; papillaa of, 
13; structure of, 11; transverse sec- 
tions of in flaccid state, 9. 

Urethral asepsis, notes on, 187. 

Urethral sttppositories, 168. 

Urethral washings (see Flushings.) 

Urethritis, acute, 34, 35; anatomo-path- 
ologic studies, rai'e in, 35; hladder, 
epididynies, and kidneys in, 37; dia- 
pedesis of leucocytes in, 35; Finger's 
and Jadassohn's researches in pos- 
terior, 35; gonococcus in, 35; mu- 
cosa in, 36; phagocytosis in, 35; 
phlebitis in, 36; post-mortem exam- 
ination of, 35: prostatitis in, 37; 
spongy hodies in. 36: urethral glands 
in. 36. 

Urethritis, dry form of, 110. 

Urethritis, follicular form, 110. 

Urethritis, mucosa, 119. 

Urethritis, papillomatosa, 151. 

Urethritis, anterior, chronic, 180; dila- 
tation in, 213, 215; instillations in 
unnecessary, 164; topical applications 
in, 222; treatment and course of, 213, 
221; treatment of hard infiltrations, 
216, 217. 

Urethritis, chronic, diagnosis of, 47; 
lacunas in, 42; Littres' glands in, 42. 
localization of, 52, 179; microscopical 



changes in epithelium, 40; in mucons 
membrane, 41; pathological anatomy, 
39; resume of, 44; leucocytes in, 52; 
secretion of, 51; Microorganism, 52; 
secretion of mucus in, 50. 

Urethritis, posterior, acute, 37. 

Urethritis, posterior, chronic, dilata- 
tion in, 224, 225; glands in, 148; lesions 
of, 143; pathology of, 144; silver 
washings in, 224; soft infiltrations in, 
147. 

Urethrocystitis, Diday's method in, 
171. 

Urethrometers, 64, 65; Otis', 66. 

Urethroscope, in chronic gonorrhea, 
185; Chettwood's, 71: Otis'. 79: 
Xitze-Oberlander, 68, 69, 73, 75: 
L. Weiss', with lamp on inclined 
plane, 85. 

Urethroscopy, cocaine anesthesia in, 
80; position of patient in, 72; tech- 
nique of, 68, 79; vapor in tubes in, 72. 

Urinary antiseptics, 158. 

Urotropin, 159. 

Vapor in tubes of urethroscope, 72. 

Wasserman on gonococcus toxines, 27. 
Weiss' urethroscope with lamp on in- 
clined plane, 85. 

Xerosis in chronic urethritis, 39. 

Zeissel on the compressor urethra?, 56. 
Zinc sulphate, 173. 



- 9. Ifctf Vk 



APR 24 1901 



